ACA Consent Form

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Please read and sign* This field is required.I am giving Consent to the Broker – Viktor VOLOSHYN: NPN 16822003 tel. 202-631-8608 email: victorybenefits@gmail.com He will be assisting me in the following categories indefinitely, until otherwise is stated: • Searching for an existing Marketplace application. • Assisting with completion of a Marketplace application for eligibility. • Assisting with plan selection and enrollment. • Assisting with ongoing account maintenance. • Changing of NPN number so he will retain AGENT of RECORD for my policy. • Renew my current plan or to change it to a new one. • Act on my behalf for my household best interest. As my producer of record, he will have access to my Protected Health Information (PHI) related to insurance support functions, such as membership maintenance, plan benefit information, transactional information, new product information, enrollment, and disenrollment. By signing this form, I confirm the producer listed above did significantly assist me with my enrollment in a Marketplace Health Plan. Additionally, by signing this form, I understand any producer currently designated on my policy, will be removed and the new producer being added will remain in effect until revoked or replaced in writing. This consent does authorize the producer listed above to speak with the Marketplace call center regarding an application. 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 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 in writing. I understand that the above printed name takes the place of my signature on this form:
First and Last name, telephone number
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I am giving Consent to the Broker – Viktor VOLOSHYN: NPN 16822003

tel. 202-631-8608, email: victorybenefits@gmail.com

He will be assisting me in the following categories until the Expiration 06/30/2050:

• Searching for an existing Marketplace application.
• Assisting with completion of a Marketplace application for eligibility.
• Assisting with plan selection and enrollment.
• Assisting with ongoing account maintenance.
• Changing of NPN number so he will retain AGENT of RECORD for my policy.
• Renew my current plan or to change it to a new one.
• Act on my behalf for my household best interest.

As my producer of record, he will have access to my Protected Health Information (PHI) related to insurance support functions, such as membership maintenance, plan benefit information, transactional information, new product information, enrollment, and disenrollment.

By signing this form, I confirm the producer listed above did significantly assist me with my enrollment in a Marketplace Health Plan. Additionally, by signing this form, I understand any producer currently designated on my policy, will be removed and the new producer being added will remain in effect until revoked or replaced in writing.

This consent does authorize the producer listed above to speak with the Marketplace call center regarding an application.

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 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 in writing.

I understand that the printed name takes the place of my signature on this form

https://form.jotform.com/232247510642045
Should be Empty:

He will be assisting me in the following categories until the Expiration 06/30/2050:

As my producer of record, he will have access to my Protected Health Information (PHI) related to insurance support functions, such as membership maintenance, plan benefit information, transactional information, new product information, enrollment, and disenrollment.

This consent does authorize the producer listed above to speak with the Marketplace call center regarding an application.

I understand that the printed name takes the place of my signature on this form