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 Bridget Richwine, NPN #1054812, has informed you of the functions and responsibilities of agents in the Marketplace, and grant permission to the Bridget Richwine 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 ongoing account/enrollment maintenance 

I understand that I can revoke, limit, or otherwise change the consents I provide through this form at any time by notifying Bridget Richwine.