CONSENT OF REPRESENTATION
With the guidance of licensed insuance brokers and certified behavioral health professionals, assists those impacted by the disease of addiction and their family and loved ones, whether in crisis or in recovery, obtain affordable health insurance in order to obtain preventative and necessary medical treatment and appropriate care.
I voluntarily give consent of representation to Licensed brokers - Nadine Psareas, Amber Robinson, Tyrus Brown, Jordan Porter, Ariel Read, Peter Psareas, Misty Baylin or Del Hughes) to guide me with the health insurance process through the ACA healthcare exchange/marketplace.
I understand all information submitted is protected under the Federal regulations governing Confidentiality and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. pts 160 & 164, and cannot be disclosed without written consent unless otherwise provided for by the regulations. I also understand that I may revoke this consent at any time, in writing, except to the extent that action has been taken in reliance on it.
I understand that by receiving insurance through the ACA healthcare exchange/marketplace, I am using tax credits to offset the cost of the chosen health insurance plan. Should I have tax-related questions I will consult with my tax professional and I will not hold Hopedealers Worldwide liable in any way. does offer a specialized tax professional to our clients at a very reduced rate.
I understand that is a 501c3 non-profit organization that provides Integrative Behavioral Health Counseling and Coaching among a variety of other support services for those in the community and no person benefits financially or is compensated from this service. Any commissions generated are given to the 501c3 non profit to serve the community. Helping and guiding people with ACA marketplace insurance is a 100% community outreach.
I give my permission (Nadine Psareas, Amber Robinson, Julia Emory, Jordan Porter, Ariel Read, Tyrus Brown, Misty Baylin or Del Hughes - licensed brokers) to serve as the health insurance agent or broker for myself and my entire household, if applicable, for purposes of enrollment in a QUALIFED health plan offered on the Federally Facilitated Marketplace.
"I give my permission to send text messages including marketing content to the Phone Number provided. Consent is not a condition of representation. Message & data rates apply. Text STOP to opt out at any time"
In the event I am not able to contact, or if the agency is unable to contact me, I give authorization for Hopedealers Worldwide to renew my policy unless or until I request otherwise.
By consenting to this agreement, I authorize the above mentioned agency and agents to view and use the confidential information provided by me in this electronic form or by phone only for one or more of the following:
Searching for an existing marketplace application
Completing an application for eligibility and enrollment in a marketplace qualified healthplan or other government insurance affordability programs, such as Medicaid and CHIP or advanced tax credits to help pay for marketplace premiums
Providing ongoing account maintenance and enrollment assistance, as necessary
Responding to inquiries from the marketplace regarding my application
I understand that the agency/agents will not use or share my personally indentifiable information (PII) for any purpose other than those listed above. The agent will insure 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 the entry on my marketplace eligibility and enrollment application will be true to the best of my knowledge.
I confirm that I have reviewed my completed application and that all information is accurate.
I understand that I do not have to share additional personal information about myself or my health with my agent 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 contacting my agency/agent or revoking it through my health sherpa dashboard.
Primary Writing Agents and Others that might not be listed:
PRINCIPAL AGENT: NADINE PSAREAS - NPN#2076170
AGENT: AMBER ROBINSON- NPN#20722293
AGENT: JULIA EMORY - NPN#20700372
AGENT: JORDAN PORTER - NPN#20786930
AGENT: ARIEL READ - NPN#20767364
AGENT: PETER PSAREAS - NPN#21786452
AGENT: MISTY BAYLIN - NPN#21731040
AGENT: DEL HUGHES: NPN# 21705290