I {fullName} confirm my permission to Gennadii Zolotov ("Agent") 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 or State Based Exchange (SBE). 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 phone only for one or more of the following:

Searching for an existing Marketplace or SBE application
Completing an application for eligibility and enrollment in a Marketplace or SBE Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace or SBE premiums
Providing ongoing account maintenance and enrollment assistance, as necessary
Responding to inquiries from the Marketplace or SBE regarding my 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 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 contacting my Agent.

Agent name: Gennadii Zolotov

Agent NPN: 21076241

Agent phone: (305) 775-3215