Marketplace Consent Form
CMS requires health insurance agents/brokers to obtain a customer's consent prior to helping them apply for a subsidy and/or enroll in a Marketplace Qualified Health Plan (QHP If you authorize AMR Insurance Services Inc. and its representatives to assist you in the health insurance enrollment process, please confirm by completing the entries below.
I, ___________________give my permission to Angelica Rivera- AMR Insurance Services 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/State-based Marketplace on the Federal Platform. By providing my consent, I authorize the above-mentioned AMR Insurance Services to view and use the confidential information, including personally identifiable 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 existing 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 advance payments of the premium tax credit 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 (pick applicable and delete the rest: agent/broker/web-broker/agency) will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The (pick one and delete the rest: agent/broker/web-broker/agency) 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 information (PHI) with my AMR Insurance Services beyond what is required on the Marketplace application for eligibility and enrollment purposes. I understand that my consent remains in effect until (365 days from now), and I may revoke or modify my consent at any time by writing to the following office address or email 4639 Corona Dr. Suite 60, CC TX 78411 or arinsurancetx@yahoo.com
Name of Primary Writing Agent: Angelica Rivera Agent
National Producer Number: 8715952
Phone Number: 361-888-4008
Email Address: arinsurancetx@yahoo.com
Name of Agency: AMR Insurance Services
National Producer Number: 20723117
Phone Number: 361-888-4008
Email Address: arinsurancetx@yahoo.com
Name of Primary Household Contact and/or Authorized Representative:
Phone Number:
Email Address:
Signature:
Date:
Thank you for trusting AMR Insurance Services Inc. to assist you with your insurance needs. We want to make sure you understand the help we will provide, please download a copy of this consent to keep for your records.
For more information, please review the:
CMS Privacy Notice on HealthCare.gov at www.healthcare.gov/privacyl, Include link to your privacy policy if available