CONSENT FORM REQUIRED BY CMS FOR ALL CURRENT, RETURNING, AND BRAND NEW ENROLLEES OF MARKETLACE HEALTH PLANS UNDER ACA(AFFORDABLE CARE ACT)

EXPIRES 01/15/2023

 IN ORDER FOR US TO ASSIST YOU WITH YOUR MARKETPLACE PLAN THIS YEAR AND GOING FORWARD PLEASE READ AND FILL OUT THE SECTION BELOW

I consent to give my permission to Xtreme Insurance, Tony Cooke my agent and staff  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. By consenting to this agreement, I
authorize the above-mentioned Agent to view and use the confidential information provided by me in writing,
electronically, or by telephone only for the purposes of one or more of the following:
ϭ͘ Searching for an existing Marketplace application;
1. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other
government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help
pay for Marketplace premiums;
2. Providing ongoing account maintenance and enrollment assistance, as necessary; or
3. Responding to inquiries from the Marketplace regarding my Marketplace application.
I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes
other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing,
and using my PII 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 I do not have to share additional 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 by contacting Xtreme Insurance OR ANTHONY Cooke by mail or by phone using the CONTACT details below:

Xtreme Insurance

2764 Pleasant Road Suite A PMB 10632

Fort Mill, SC 29708

XTREME@XTREMEINSURANCE.BIZ

(803)558-1620 OFFICE (843)999-0124 ALTERNATE (845)594-6572 CELL