Consumer Authorization Form

    The Department of Health and Human Services requires licensed sales agents to obtain consumer consent prior to providing assistance to Marketplace consumers. By signing this form, you acknowledge that the agent has informed you of the functions and responsibilities of agents in the Marketplace, and grant permission to the authorized licensed sales agent to conduct the following activities:

    • Conduct a search for the consumer application through the Marketplace

    • Assist with completing an eligibility application

    • Assist with plan selection and enrollment

    • Assist with ongoing account/enrollment maintenance

    The Department of Health and Human Services requires licensed sales agents to obtain consumer consent prior to providing assistance to Marketplace consumers. By signing this form, you acknowledge that the agent has informed you of the functions and responsibilities of agents in the Marketplace, and grant permission to the authorized licensed sales agent to conduct the following activities:

    • Conduct a search for the consumer application through the Marketplace

    • Assist with completing an eligibility application

    • Assist with plan selection and enrollment

    • Assist with ongoing account/enrollment maintenance

    Authorized Licensed Sales Agent: JANE MOERLIE

    I, give my permission to JANE MOERLIE to create, collect, disclose, access, maintain, store, and/or use my PII in order to carry out the roles and responsibilities of a licensed sales agent. I understand that JANE MOERLIE might need to create, collect, disclose, access, maintain, store, and/or use some of my PII in order to provide this assistance.

    Exceptions or Limitations to Consent

    I understand that I can revoke, limit, or otherwise change the consents I provide through this form at any time. If I don’t make any limitations, exceptions, or changes to my consents now, I can still do so at any time in the future by notifying  JANE MOERLIE . I make the following exceptions, limitations, or changes:

    (Required: either your exceptions or type "none")

    I understand that:

    1. I don’t have to provide  JANE MOERLIE with any information that I do not want to provide. However, the help   JANE MOERLIE provides is based only on the information I provide, and if the information   given is inaccurate or incomplete,  JANE MOERLIE may not be able to offer all the help that is   available for my situation.

    2. should ask me to provide only the minimum amount of my PII that is necessary to help me.

    3. must make sure that my PII is kept private and secure when creating, collecting, disclosing, accessing, maintaining, storing, and/or using my PII. JANE MOERLIE must follow the   privacy and information security standards that apply to them.

    4. If I give my contact information when signing this form, my general consent includes permission for JANE MOERLIE  to follow up with me about applying for or enrolling into coverage after my first meeting with them.

    5. Once I have signed this authorization form, I can expect JANE MOERLIE  to help me without asking me to sign another authorization form.

    (Required) By checking this box, I understand and agree that I am signing this document electronically, and I have the right to ask to sign a paper copy of this document if I prefer. A copy of this electronic document is also being sent to the email address you provided here. It is your responsibility to make sure the document arrives in your email, please check your spam folder if you do not see it, and contact us if needed and, we will provide a paper copy of this signed document to you.

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