Legal Disclosure:

The content of this document holds no legal force or effect and is not intended to bind the public in any way unless specifically incorporated into a contract. This document is solely intended to provide clarity to the public regarding existing requirements under the law. This sample consent form does not replace any registered agent in the state, registered broker, or other forms required by a QHP issuer in order to facilitate commission payments to the appropriate agent or broker for assisting a particular consumer.

Purpose Statement:

Registered agents and brokers who assist consumers in applying for and enrolling in Marketplace coverage must document the consumer's consent before accessing or updating their Marketplace information. CMS does not prescribe how agents and brokers should document consent. Instead, there are various formats that may be acceptable for agents and brokers to use to document consumer consent, such as through a recorded phone call, a text message, an email, an electronic document with digital signatures, a physical document with printed signatures, etc. The consent form serves as an example of how agents and brokers can document consent using a physical document with wet signatures. Since this sample consent form is a best practice for obtaining consumer consent, you may adapt the form to address the needs of your specific business model while also complying with the CMS requirement to document consumer consent prior to assisting them in enrolling in Marketplace coverage, even before conducting a search for individuals. For example, if an Agency is involved, it may specifically clarify who else within the Agency, besides the Writing Agent, can view and use the consumer's PII to assist the Writing Agent in enrolling the consumer in Marketplace coverage for compliance, commissions, or other relevant purposes deemed appropriate.

I, give my permission to ______________________ who has the consumer's consent, to act as a health insurance agent or broker for me and my entire household, if applicable, for the purpose of enrolling in a Qualified Health Plan offered in the federally facilitated Marketplace. By giving my consent to this agreement, I authorize the aforementioned Agent to view and use the confidential information provided by me in writing, electronically, or by phone solely for one or more of the following purposes: To search for an existing Marketplace application; To complete an eligibility application and enrollment in a Qualified Health Plan from the Marketplace or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums; To provide ongoing account maintenance and enrollment assistance as needed; or To respond to Marketplace inquiries regarding my Marketplace application. I understand that the Agent will not use or share my personally identifiable information (PII) for any purpose other than those listed above. The Agent will ensure that my PII is kept private and secure by collecting, storing, and using my PII for the previously indicated purposes. I confirm that the information I provide for entering my Marketplace enrollment and eligibility application will be true to the best of my knowledge and belief. 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 can revoke or modify my consent at any time.