OMB Control Number: 0938-1438

Expiration Date: 07/31/2028
CMS Consent Form for Health Insurance Marketplace Agents and Brokers

I give my permission to SHACKISHA CLARK to serve as the health insurance agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following:
1. Searching for an existing Marketplace application;
2. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums;
3. Providing ongoing account maintenance and enrollment assistance, as necessary; or
4. Responding to inquiries from the Marketplace regarding 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 kept private and safe when collecting, storing, and using my PII for the stated purposes above.

I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by contacting Healthcare.gov or my state-based marketplacee exchange.

Name of Primary Writing Agent: SHACKISHA CLARK

Email Address: insurance@lifetimetaxprofessionals.com

Phone Number: 678-994-4069

National Producer Number: 19092685

It may become useful during getting quotes and filling out applications to communicate by email, text message (“SMS”), or other electronic methods of communication. Be informed that these methods, in their typical form, are not confidential means of communication. If you use these methods to communicate, there is a reasonable chance that a third party may be able to intercept and eavesdrop on those messages from your end.

The kinds of parties that may intercept these messages include, but are not limited to:

• People in your home or other environments who can access your phone, computer, or other devices that you use to read and write messages
• Your employer if you use your work email.
• Third parties on the Internet such as server administrators and others who monitor Internet traffic
• Hackers or other bad actors If there are people in your life that you don’t want accessing these communications, please talk with your broker about ways to keep your communications safe and confidential.

CONSENT FOR TRANSMISSION OF PROTECTED HEALTH INFORMATION BY NON-SECURE MEANS I have been informed of the risks, including but not limited to my confidentiality in treatment, of transmitting my protected health information by unsecured means. I understand that I am not required to sign this agreement in order to receive a quote or fill out an application. I also understand that I may terminate this consent at any time. I consent to allow Shackisha Clark to use unsecured email and mobile phone text messaging to transmit to me the following protected health information:

I understand that Shackisha Clark also offers the following, more secure means of communication which include voicemail, encrypted email, secure portals, and secure online forms. While it cannot be guaranteed that they will prevent 100% of confidentiality breaches, they are designed to support the confidentiality of communications. 

YOU UNDERSTAND IF YOU DO NOT SIGN THIS FORM, THAT YOU CAN ONLY SEND INFORMATION THROUGH SECURE MEANS ONLY.