ACA Consent Form

Name

First NameLast Name

Date of Birth

Social Security Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Format: (000) 000-0000.

Additional family members

Household size and income

Select a plan

Medicare Number

Part A Date

Part B Date

Medicaid Number

Referred by

First NameLast Name

I hereby give my consent for Brett Gainey 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 the

1. 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 ACA

I 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 enrollment

process 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 Brett Gainey.

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 writting

By signing below, I acknowledge that I have read and understood the contents of this ACA consent form, and I voluntarily give my consent for ACA enrollment and compliance purposes.

Signature

Client Intake Form