I, ___ ___, give my permission to Jesse Smedley, NPN 9655617 to serve as the health insurance broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the State or Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned Broker and his office staff 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:
- 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; or
- Responding to inquiries from the Marketplace regarding my Marketplace application.
I understand that the Broker will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Broker will ensure that my PII is kept private and safe when collecting, storing, and using my PII 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 I do not have to share additional personal information about myself or my health with my Broker beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by phone or email.
Name of Primary Writing Broker: Jesse Smedley
Broker National Producer Number: 9655617
Name of Agency: Smedley Insurance Group, Inc. DBA: iHealthBrokers
Agency National Producer Number: 11171590
Phone Number: (866) 260-9829
Email Address: support@iHealthBrokers.com
I understand that failure to adhere to all of the information below may result in loss or repayment of any or all tax credits to the IRS. By completing and signing this form I am confirming receipt and understanding of all of the following:
1. I understand the 2024 Adjusted Gross and household information I provided qualifies me for Premium Tax Credits.
● I understand that if I underestimate my 2024 Adjusted Gross Income, the difference must be paid when federal income tax returns are filed.
● I understand that if I overestimate my 2024 Adjusted Gross Income, the difference will be issued as a refundable credit when federal income tax returns are filed.
2. I am aware that I must file my 2024 taxes and reconcile my premium tax credit. 1095A forms will be mailed to members in January 2024.
3. I have provided information for all dependents and understand that if I am legally married I am required to file taxes jointly.
4. I understand that if I qualify for health insurance through my employer, a spouse’s employer, a parent’s employer, Medicaid, TRICARE, VA Coverage, etc., I may not be eligible for the premium tax credit. To be eligible for the premium tax credit my share of the monthly premium in the lowest-cost plan offered to me must be higher than 9.12% of your household income.
5. I understand I may be denied coverage if I did not disclose the use of tobacco products more than 4 times a week in the past 6 months in any form (cigarettes, cigars, oral tobacco, pipe, etc.), during the application process.
