This model form is intended for informational purposes. This form can be personalized by an agent, broker, or agency intending to utilize the form to collect consumer consent.

CENTERS FOR MEDICARE & MEDICAID SERVICES

CMSOMB Control Number: 0938-1438 Expiration Date: 06/30/2026

Legal Disclosure:

The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law. This model consent form will not supersede any State Agent of Record, Broker of Record, or other form required by a QHP issuer for purposes of making commission payments to the proper agent or broker for assisting a particular consumer.

Purpose Statement:

Registered agents and brokers assisting consumers apply for and enroll in Marketplace coverage must document consumer consent prior to accessing or updating their Marketplace information. CMS does not prescribe the manner in which agents and brokers must document consent. Instead, there are different formats that may be acceptable for agents and brokers to use to document consumer consent, such as via a recorded phone call, text message, email, electronic document with digital signatures, physical document with wet signatures, etc. This model consent form serves as an example for how agents and brokers may document consent via a physical document with wet signatures.

Since this model consent form is a best practice for obtaining consumer consent, you may tailor the form to address the needs of your specific business model in addition to meeting the CMS requirement to document consent from a consumer prior to assisting the consumer enroll in coverage in the Marketplace, including prior to conducting a person search. For example, if an Agency is involved, you may clarify specifically who else within the Agency other than the writing Agent is able to 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 as you see fit.

CMS Model Consent Form for Marketplace Agents and Brokers

I , {name}, give my permission to ART Risk Financial and Insurance Solutions 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 on the Federally Facilitated Marketplace. 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:

1. Searching for an existing Marketplace application;
2. 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;
3. Providing ongoing account maintenance and enrollment assistance, as necessary; or
4. Responding to inquiries from the Marketplace regarding my Marketplace application.

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 emailing my request of such to: info@yourinsuranceresource.com.

Name of Primary Writing Agent: Virginia S. Hart

Agent National Producer Number: 1311139

Phone Number: 661-257-6242

Email Address: info@yourinsuranceresource.com

 

Name of Agency (if applicable): ART Risk Financial and Insurance Solutions

Agency National Producer Number:  1311139

Owner of Agency: Virginia S. Hart

Phone Number: 661-257-6242

Email Address: info@yourinsuranceresource.com