Form

Name*

First NameMiddle NameLast Name

Phone Number

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SS # *

D.O.B.

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Additional Family Members:

Household Size and Income?

Do you have Health Insurance?*

Medicare #
Medicaid #
Part A Date:
Part B Date:

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Select a Plan

Comments:

I hereby give my consent for Mark Lewis Warren Jr to use and disclose my personal and health information as necessary for the purposes of ACA enrollment and compliance. This consent is granted in accordance with the regulations and requirements of the Affordable Care Act and any applicable state and federal laws.I understand that this consent is being obtained for the1. To determine my eligibility for health insurance coverage through the ACA marketplace.2. To facilitate the enrollment process in ACA-compliant health insurance plans.3. To verify my identity and personal information for ACAI understand that the following information may be disclosed to appropriate authorities and agencies for ACA enrollment and compliance purposes:- Personal information, including name, date of birth, address,- Income and financial information to determine eligibility for premium tax credits and cost-sharing reductions.- Health information required for the evaluation of health insurance plans.- Any other information necessary for ACA enrollment and compliance.This consent will remain in effect until the ACA enrollmentprocess is completed, and I am successfully enrolled in an ACA-compliant health insurance plan. I may revoke this consent at any time by providing written notice to [Your Health Insurance Company Name].I understand that I have the right to:- Review and obtain a copy of this consent form.- Request a list of disclosures made using this consent. - Revoke this consent at any time in writing

Signature*