Authorization

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 listed below, and grant permission to the authorized, licensed sales agent 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
Terminate plan when circumstances change

Authorized Licensed Sales Agents: Mary Reynolds Insurance LLC, Mary Reynolds 7495587, Rhonda Lynn 18169929 & 21064956, Heather Khan 19974011

I understand that:
1. I do not have to provide Mary Reynolds, Rhonda Lynn or Heather Khan with any information that I do not want to provide. However, the help I receive is based only on the information I provide, and if the information I give is inaccurate or incomplete, the agent/s may not be able to offer all the help that is available for my situation.
2. Mary Reynolds, Rhonda Lynn and/or Heather Khan should ask me to provide only the minimum amount of my Personally Identifiable Information (PII) that is necessary to help me.
3. Mary Reynolds, Rhonda Lynn and/or Heather Khan must make sure that my PII is kept private and secure when creating, collecting, disclosing, accessing, maintaining, storing, and/or using my PII. The agent/s must follow the privacy and information security standards that apply to them.
4. If I give my contact information when signing this form, my general consent includes permission for Mary Reynolds, Rhonda Lynn and/or Heather Khan to follow up with me about applying for or enrolling into coverage after my fist meeting with them.
5. Once I have signed this authorization form I can expect Mary Reynolds, Rhonda Lynn and/or Heather Khan to help me without asking me to sign another authorization form, unless I make changes to my application data in the future.

Exceptions or Limitations to Consent
I understand that this authorization will be valid indefinitely or until I revoke, limit, or otherwise change the consents I provide through this form. If I don't make any revocations, limitations, exceptions, or changes to my consent now, I can still do so at any time in the future by notifying Mary Reynolds, Rhonda Lynn and/or Heather Khan by phone call or email.

I make the following exceptions, limitations or changes to my consent:

Skip if None

I, First Name* Last Name* Street Address* City* State* Zip* Phone Number* give my permission to Mary Reynolds, Rhonda Lynn and Heather Khan to create, collect, disclose, maintain, store, and/or use my Personally Identifiable Information (PII) in order to carry out the roles and responsibilities of a licensed sales agent. I understand that Mary Reynolds, Rhonda Lynn and Heather Khan might need to create, collect, disclose, access, maintain, store, and/or use some of my PII in order to provide this assistance.

Primary Writing Agent:*

Rhonda Lynn 18169929/21064956, rhonda@maryreynoldsllc.comMary Reynolds 7495587, mary@maryreynoldsllc.com

Agency Name: Mary Reynolds Insurance, LLC
Agent Owner & National Producer Number: Mary Reynolds 7495587
Phone Number: 541-592-6262

Your relationship to the consumer*

Signature*

Signature Date*

Date

Authorized representative sign above and enter name

First NameLast Name

Consumer Authorization Form