Georgia Access Consumer Consent Form (PY2025)

I give permission to Josh Murtha Insurance LLC (NPN 20208884/GA 222534) and it's agents and representatives to serve as my 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 agency and it's agents & representatives to view and use the confidential information provided by me in writing, electronically, or by telephone for the purpose of one or more of the following:

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.
I understand that the agency may submit my completed application for review by Georgia Access, and I authorize them to do so on my behalf.
I agree that I have been informed and agree with all the disclaimers included in my exchange application.
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.
This consent form is valid for Plan Year 2025 and shall terminate at 11:59pm on December 31st, 2025, unless it is revoked by the consumer.
I give any member of the above mentioned 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 consent, but if I do not, I will need to document a new consent every time I require future assistance from my agent.

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.*

AgreeDisagree

I understand that the agency may submit my completed application for review by Georgia Access, and I authorize them to do so on my behalf.*

AgreeDisagree

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

AgreeDisagree

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.*

AgreeDisagree

This consent form is valid for Plan Year 2025 and shall terminate at 11:59pm on December 31st, 2025, unless it is revoked by the consumer.*

AgreeDisagree

I give any member of the above mentioned 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 consent, but if I do not, I will need to document a new consent every time I require future assistance from my agent.*

AgreeDisagree

Legal Name*

First NameLast Name

Email*

example@example.com

Mobile Number*

Please enter a valid phone number.

Social Security Number*

ex. 555555555

Date*

Date

Signature*