Georgia Access Consent Form

Georgia Access Consent Form

Agent name Barton Herndon npn 8106026 Agency name Benefit Consultants Group LLC NPN 19070382
Notes
Do you have Medicare?*
Do you have Medicaid?*
Do you have Tricare or VA Benefits?*
Name*

First NameLast Name
Date of Birth*
Social Security Number*
Sex*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Additional Family Members
Household size and annual income*
I have reviewed the plan details of the plan selected below and I am asking to be enrolled into that plan*
Referred by*

First NameLast Name
I give permission to the above mentioned agent/agency to serve as the health insurance agent for
myself and my entire household if applicable, for enrollment in a Qualified Health Plan offered on the
Georgia State-based Exchange (Georgia Access). By consenting to this agreement, I authorize the
above-mentioned agent/agency to view and use the confidential information provided by me in
writing, electronically, or by telephone only for the purpose of one or more of the following:

1. I give permission to access my information for the purpose of helping me complete an
application for eligibility and enrollment in a Qualified Health Plan or other insurance
affordability programs, such as Medicaid and PeachCare for Kids® (CHIP) or advance tax
credits to help pay for insurance premiums.
Signature*

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2. I agree that I have been informed and agree with all the disclaimers included in my exchange
application.
Signature*

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3. I understand the plan(s) I am being enrolled in and agree that I wish to be enrolled in that plan;
I understand that I may cancel the delegation at any time either within the Georgia Access
portal, a certified partner portal, or by calling the Georgia Access contact center at 1-888-
687-1503.
Signature*

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4. I give the agent and any member of their agency permission to assist me
in maintaining my information and changing my plans in the future without requiring consent.
I understand that I am not obligated to provide this consent, but if I do not, I will need to
document a new consent every time I require future assistance from my agent.
Signature*

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