Consent Form for Marketplace

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:

• Searching for an existing Marketplace application
• 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
• Providing ongoing account maintenance and enrollment assistance, as necessary
• Responding to inquiries from the Marketplace regarding my application

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 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 confirm that I have reviewed my complete application and that all information is accurate

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) 414-5399
Email 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