I _______________________, give my permission to Lillie Green to serve as the health insurance agent for myself and my entire household, if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally-facilitated Marketplace/State-based Marketplace on the Federal Platform. By providing my consent, I authorize the above-mentioned agent to view and use the confidential information, including personally identiafiable; information (PII), provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following:
1. Searching for an existling Marketplace application;
2. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or an application for government insurance affordability programs such as Medicaid and Chip or advanced payments of the premium tax credit to help pay for Marketplace premiums,
3. Providing ongoing account maintenance and enrollment asistance, as necessary, or
4. Responding to inquiries from the Marketplace reqarding my Marketplace application.
I understand that the agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The agent will ensure that my PII is protected when creating, collecting, disclosing, accessing, maintaining, storing, and using my PII for the stated purposes above.
I understand that I do not have to share additional PII or protected health inforation (PHI) with my agent beyond what is required on teh Marketplace application for eligibility and enrollment purposes.I understand that my consent remains in effect until I revoke it, and that I may revoke, limit, or change this consent at any time by contacting my agent at 281-914-3404 or tx3insurance@gmail.com or by contacting the Marketplace at www.healthcare.gov.
Name of Agent: Lillie Green
Agent National Producer Number: 7971967
Phone Number: 281-914-3404
Email: tx3insurance@gmail.com