I give Belle Vida Insurance my permission to serve as the health insurance agent or broker for myself and my entire household if applicable, for purposes of enrollment in an Individual Coverage Health Reimbursement Arrangement (ICHRA) or Qualified Health Plan (QHP) offered on the Federally Facilitated Marketplace. By consenting to this agreement, I agree to let Belle Vida Insurance 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: Completing an application for eligibility and enrollment in an ICHRA through my employer. Searching for an existing Marketplace application. Searching the Marketplace Qualified Health Plan for healthcare that uses tax credits to help pay for Marketplace premiums if my employer offered coverage is not considered afordable. Providing ongoing account maintenance and enrollment assistance, as necessary; or Responding to inquiries from the insurance carriers or the Healthcare Marketplace regarding my application.
I understand that the Agent will not use or share my personal identifiable information (PII) for any purpose 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 notifying Belle Vida Insurance.