AS REQUIRED UNDER CMS-9899-F AMENDMENT OF 45 CFR § 155.220

I give my permission to BenefitsDallas, Inc, and/or their staff to provide the following services on behalf of myself, and my entire household if applicable.

1. Search for an existing Marketplace application;

2. Completing an application for eligibility and enrollment in a marketplace Qualified Health Plan or government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace Premiums or enrollment in off-exchange insurance products as applicable;

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 BenefitsDallas, Inc, and/or their staff will not share my personally identifiable information (PII), and they will ensure that my PII is kept private and safe when collecting, storing, and using my information for the stated purposes above.

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 my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time. I understand that requests must be made in writing, either by sending the request via certified mail to the address below or via email to info@benefitsdallas.com.

BenefitsDallas, Inc | 214-340-0115 | 10830 N Central Expy Ste 171 Dallas, TX 75231

Jo Ann Charron | jcharron@benefitsdallas.com | NPN #1934189

Disclosure: This consent form does not supersede any State or Federal Agent of Record, Broker of Record, or other form required by a QHP issuer.

After you submit this form, you will be automatically redirected to our quoting, enrollment, and servicing website to explore affordable healthcare options. We need information about your income, current physicians, and prescriptions to generate an accurate quote and determine your subsidy eligibility.

 
Start By:

• Providing your Zip Code, Name, Email, Phone Number
• Age(s) & Gender(s) of anyone in your household needing coverage.
• How many live in your household & total estimated income.

You will now see your initial subsidy eligibility estimate. If your enrollment event occurs outside of the yearly open enrollment, you might have to choose your special enrollment event.

Next, share your medical preferences:

• Add the preferred Doctors, Specialists, or Hospitals you hope to have covered under your plan.
• Add your current prescription drugs.

Tip: Most Affordable Care Act (ACA) plans require a primary care doctor.

 

Self-Enroll or Get Our Help

Your personalized quotes, including any estimated subsidies you may be eligible for, are now displayed. Feel free to explore your different carriers, plan options, pricing, and even enroll independently. Often, you may find that some doctors and drugs are covered under one plan but not another. After speaking with a BenefitsDallas agent, you may feel more confident about making your final decision.

If you'd like our help, please call us at 214-340-0115 or email individuals@benefitsdallas.com for expert guidance once you've entered the above info. We can more confidently guide you to the most appropriate health plan because we can now access the specifics of your unique needs and situation.

Tip: While you will see options to add dental coverage, we offer alternatives that provide more robust coverage.