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 [primary as listed on your marketplace application] give my permission and consent to AMR Insurance Services Inc. and its representatives to be my health insurance agent/broker for myself and my entire household [if applicable], for purposes of enrolling in a Qualified Health Plan on the Federally Facilitated Marketplace.
By consenting to this agreement, I authorize AMR Insurance Services Inc. and its representatives to view, access, and use the confidential information I provide in writing, electronically, or over the phone throughout the plan year only for the purposes of one or more of the following activities:
1. Conduct a search for any existing Marketplace application,
2. Assist with completing an eligibility application and enrollment in a Marketplace Qualified Health Plan, or advance premium tax credits to help pay for Marketplace premiums,
3. Assist with plan selection and enrollment,
4. Assist with ongoing account/enrollment maintenance, enrollment assistance, correcting errors, as necessary, and
5. Respond to inquiries from the Marketplace, as needed, regarding my Marketplace application.
I understand AMR Insurance Services Inc., and its representatives will not use or share my personally identifiable information (PII) for any purposes other than those listed above and will ensure my PII is kept private and safe when collecting, storing, and using my PII for the specific purposes indicated above.
I confirm the information I give for my Marketplace eligibility and enrollment application will be true and correct to the best of my knowledge. I know I am under no obligation to share additional personal information about myself or my health with AMR Insurance Services Inc. or its representatives unless it is needed for the eligibility and enrollment application.
I understand my consent will stay in effect until I choose to cancel it, and I can do so at any time in writing [office address] or[email].
3649 Leopard ST Suite 414, CC TX 78408 or arinsurancetx@yahoo.com
Please note that AMR Insurance Services Inc. will be compensated by the insurance carrier if you chooseto purchase coverage. For more information, please read our Broker Compensation Disclosure (include hyperlink, if available
Name of Primary Writing Agent: Angelica Rivera Agent
National Producer Number: 8715952
Phone Number: 361-888-4008
Email Address: arinsurancetx@yahoo.com
Thankyou 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