Broker Agent NPN :
Consent Form for help enrolling in the Florida & Pennsylvania Health Insurance Marketplace.
Agent/Broker Name:_____________________________ I, ______________________________, give my permission to use the services of agent/broker to help me with my application on the Health Insurance Marketplace. To help me, the agent/navigator may need to see/use my Personally Identifiable Information (PII). The agent/navigator will only use my PII to do their work. This includes:
● Telling me about all of my health insurance options on the Marketplace and other health programs I am eligible for, such as Medicaid and CHIP, in a fair and truthful way.
● Telling me about all programs I might be eligible for that can help me lower my costs (tax credits or costs haring reductions).
● Helping me complete my application for health insurance on the Marketplace in these ways: ○ Helping me set up an email account if needed, so I can apply to the Marketplace. The agent/navigator will not keep my passwords/username.
○ Helping me sign up for a health insurance plan on the Health Insurance Marketplace.
● Helping me with any complaints or questions I may have about my health insurance application or eligibility.
● The agent/Broker will do his/her best to tell me about all of my health insurance options and financial help on the Marketplace.
● The agent/broker will choose a health insurance plan for me with my approval.
● The agent/broker will make sure that my PII is kept private and safe when collecting, storing, and using my PII and my authorized representative’s PII to apply to the Marketplace.
● I do not have to give any information to the agent/navigator. This means I do not have to share personal information about myself or my health.
● The agent/broker gives help based on the information that I give. If the information I give is not true or complete, the agent/broker may not be able to help in all the ways that he/she can. I, ________________________________, confirm that the information I provide on my Health Insurance Marketplace application will be true to the best of my knowledge. I also agree that the agent/broker helping me has explained that I have a legal responsibility to report the required information for myself and all the family members who are applying. ————————————————————————-
Consumer Date of Birth
Consumer Signature /Phone
DateFollow All Horizon Financial Services, Get Social