Consumer Consent Form

Consumer Consent Form

for Health Insurance Marketplace Agent and/or Agency
I, First Name* Last Name(s)* , give my permission to Lindsay Blanchard of HealthLink KC LLC, to serve as the health insurance agent or broker for myself and my entire household, if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally-facilitated Marketplace/State-based Marketplace on the Federal Platform. By providing my consent, I authorize the above-mentioned agent/agency to view and use the confidential information, including personally
identifiable information (PII), provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following:
1. Searching for an existing Marketplace application;
2. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or an application for government insurance affordability programs, such as Medicaid and CHIP or advance payments of the premium tax credit to help pay for Marketplace premiums;
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 the agent/agency will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The agent/agency will ensure that my PII is protected when creating, collecting, disclosing, accessing, maintaining, storing, and using my PII for the stated purposes above.
I understand that I do not have to share additional PII or protected health information (PHI) with my agent/agency beyond what is required on the Marketplace
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 by sending an email request to Lindsay Blanchard at HealthLink KC LLC at insurance@healthlinkkc.com.
Client Contact Information*
Relation to Primary Household Contact*

SelfAuthorized Representative
Signature*

Powered by Jotform SignClear
Date Signed*

MonthDayYear
Date

Agent/Broker Information

Name of Primary Writing Agent:	Lindsay Blanchard
Agent National Producer Number:	20846481
Phone Number:	(913) 708-5100
Email Address:	Insurance@HealthLinkKC.com

Agency Information

Name of Primary Writing Agency:	HealthLink KC LLC
Agency National Producer Number:	21045510
Phone Number:	(913) 708-5100
Email Address:	Insurance@HealthLinkKC.com

Should be Empty: