Health Insurance Authorization Form

Name of insurance agency: Insurance Marketplace Agency licensed as HPO
Owner of agency: Integrity
Owner phone: 503-928-6918
Owner email address: info@healthplansinoregon.com

Name of Primary Writing Agent*

Agent/Broker Email Adddress

Agent Phone Number

Please enter a valid phone number.

Agent/Broker Email Address

example@example.com

Name of Primary Applicant*

First NameMiddle NameLast Name

Contact Number*

Please enter a valid phone number.

Email Address*

example@example.com

Date of Birth*

Date

I give my permission to the Agent/Broker listed above to serve as the health insurance agent or broker for myself and my entire household if applicable, for purposes of enrollment in a qualified health plan offered through the Oregon Health Insurance Marketplace. By consenting to this agreement, I authorize the above-mentioned Agent/Broker 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 Oregon Health Plan (Medicaid/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 Agent/Broker will not use or share my personally identifiable information (PI) for any purposes other than those listed above. The Agent/Broker will ensure that my PIl is kept private and safe when collecting, storing, and using my Pl 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/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. I may revoke or modify my consent at any time by emailing or calling the Agent/Broker, agency or agency owner listed below.

Applicant Name*

First NameLast Name

Client Signature*

Signed Date*

Date

Authorized Representative

First NameLast Name

Relationship to Applicant

Representative Signature

Signed Date

Date

Disclaimer Advance Premium Tax Credit Disclosure
I understand that I will lose my premium tax credit if I'm found eligible for affordable other minimum essential coverage. like coverage through my job, OHP, VA or Medicare. I also understand that if I accept my employer's HRA (Health Reimbursement Arrangement) and it is considered "affordable," I'm not eligible for the premium tax credit for my Marketplace coverage. I also understand that if I don't contact the Health Insurance Marketplace about my eligibility for other affordable coverage, I will lose my coverage through the Marketplace and/or may pay back any tax credits I received. I understand that because the premium
tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents: I must file a federal income tax return every year. If I'm married at the end of the year, I must file a joint income tax return with my spouse. I also expect that no one else will be able to claim me as a dependent on their federal income tax return. I'll claim a personal exemption deduction on my federal income tax return for any individual listed on this application as a dependent who is enrolled in coverage through the Health Insurance Marketplace and whose premium for coverage is paid in whole or in part by advance payments. If any of the above changes, I understand that it may impact my ability to get the premium tax credit. I also understand that when I file my federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I understand that if the income on my tax return is lower than the amount of income on my application, I may be eligible to get an additional premium tax credit amount. On the other hand, if the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax.