I, First Name Last Name (name of primary household contact), give my permission to Rosa Wise and The Insurance Expo, LLC to serve as the Health Insurance Agent or broker for myself and my entire household if applicable, for purpose 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 phone only for one or more of the following:
I understand that the Agent will not use or share my personally identifiable information (PHI) for any purpose other than those listed above. The Agent will ensure that my PHI is kept private and safe when collecting, storing, and using my PHI for the stated purpose.
I understand that I do not have to share additional personal information about my self or my health with my Agent beyond what is required on the application for eligibility and enrollment purpose. I understand that my consent remains in effect until revoke it, and I may revoke or modify my consent any time by emailing svc.ins.expo@gmail.com. Agent Information: Name of Agent: Rosa Wise Agent NPN: 11564178 Phone Number: (407) 414-5399Email address: theinsuranceexpo@gmail.com Primary applicant:Name of Primary household Contact: First Name Last Name Authorized representative (if applicable): First Name Last Name Street Address Address Line 2 City State Zip Phone Number: Area Code Phone Number Email