I give my permission to Rachel Laughlin 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 providing my consent, I authorize Rachel Laughlin 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:
1. Searching for an existing Marketplace application
2. 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
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 Rachel Laughlin will not use or share my personally identifiable information (PII) for any purposes other than those listed above. Rachel Laughlin will ensure that my PII is kept private and safe when creating, collecting, disclosing, accessing, maintaining, storing, and using my PII for the stated purposes above.
I understand that I do not have to share additional PII or protected health information (PHI) with Rachel Laughlin beyond what is required on the Marketplace
application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke or modify my consent at any time.
Licensed and Certified Marketplace Broker: Rachel Laughlin
Agent National Producer Number: #19427971
Agency National Producer Number: #5779282
Phone: (503) 282-0827
rachel@laughlinagency.com
Licensed and Certified Marketplace Broker: Rachel Laughlin
Agent National Producer Number: #19427971
Agency National Producer Number: #5779282
Phone: (503) 282-0827
rachel@laughlinagency.com