CONSENT FOR BROKER ASSISTANCE
AS REQUIRED UNDER THE 2023 CMS-9899-F AMENDMENT OF 45 CFR § 155.220
This consent form outlines your rights. Please read it carefully.
As a licensed Health Insurance Broker, Jennifer W. Lopez has completed the annual Affordable Care Act certification by the Federal Marketplace. With this yearly training, and an individual or family's formal consent, brokers are authorized to search for and assist households with their Marketplace account. The purpose of this form is to receive your informed written consent.
Terms of Consent
I give my permission to Jennifer Lopez to provide the following services on behalf of myself, and my entire household if applicable.
I give my permission to Jennifer W. Lopez to provide the following services on behalf of myself, and my entire household if applicable.
1. Search for an existing Marketplace application; 2. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace Premiums or enrollment in off-exchange insurance products as applicable. 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 Jennifer Lopez will not share my personally identifiable information (PII) and they will ensure that my PII is kept private and safe when collecting, storing, and using my information 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 my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time. I understand that requests must be made in writing, either by sending the request via certified mail to the address below or via email to jenlopez@fittoyouinsurance.com
Agent Point of Contact
My Broker - Jennifer Lopez, (443-668-0732), JenLopez@fittoyouinsurance.com.com, NPN:20516126
Household Contact Information
Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Zip Code
*
Zip Code
Phone Number
*
Please enter a valid phone number.
Email
example@example.com. This will be used to notify you if we have any trouble accessing your Healthcare.gov accout.
You must agree to the following terms before you submit:
You must agree to the following terms before you submit (please check all):
*
I understand that by hitting submit below, I am attesting that the information provided is true and correct to the best of my abilities.
I understand that by hitting submit below, that I am authorizing broker Jennifer W. Lopez to be listed as the broker of record on my Marketplace account.
I understand that by giving this authorization, I consent to have the broker access my data within my states designated exchange.
I understand that I may revoke access by request at ANY time directly with the Exchange without cause OR by emailing my request to my broker.
Signature
*
Submit
Submit
Should be Empty: