ACA Consumer Authorization Form

ACA Consumer Authorization Form

The Department of Health and Human Services requires licensed sales agents to obtain consumer consent prior to providing assistance to Marketplace consumers. By signing this form, you acknowledge that the agent has informed you of the functions and responsibilities of agents in the Marketplace, and grant permission to authorized licensed sales agents to conduct the following activities:
* Conduct a search for the consumer application through the Marketplace

* Assist with completing an eligibility application

* Assist with plan selection and enrollment

* Assist with ongining account/enrollment maintence
Client or authorized representative:*
Email Client or authorized representative:
example@example.com
Date of birth:*

MonthDayYear
Date of the review: *
Assisting agent:
Signature*

Exceptions or Limitations to Consent: I understand that I can revoke, limit, or otherwise change the consents I provide through this form at any time. If I don’t make any limitations, exceptions, or changes to my consents now, I can still do so at any time in the future.
Should be Empty: