Marketplace Electronic Enrollment Consent Form

The Centers for Medicare and Medicaid Services (CMS) requires licensed sales agents to obtain consumer consent prior to providing assistance to Marketplace consumers. By consenting to this agreement, I authorize the above-mentioned Agent 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 _________________, give my permission to Sydney Williams 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 Federally Facilitated Marketplace.

I understand that the Agent will not use or share my personally identifiable information PII for any purposes other than those listed above The Agent 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 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 submitting it in writing.

 Consumer or Authorized Representative

Agent/Broker

Writing Agent/Broker: Sydney Williams

Agent/Broker National Producer Number: 20844930

Agent/Broker Email: Sydneywilliamsinsurance@gmail.com

Thank you for choosing Ember Advisory Group to assist you with your insurance needs.