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.
2. I agree that I have been informed and agree with all the disclaimers included in my exchange application.
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 (if in GA), or healthcare.gov for other (FFM) states, a certified partner portal, or by calling the Georgia Access contact center at 1-888-687-1503 (in GA), or the healthcare marketplace for FFM states, or by contacting my agent at: monica.hunt16@gmail.com
I understand that this consent is being obtained:
1. To determine my eligibility for health insurance coverage through the ACA marketplace.
2. To facilitate the enrollment process in ACA-compliant health insurance plans.
3. To verify my identity and personal information for ACA
I understand that the following information may be disclosed to appropriate authorities and agencies for ACA enrollment and compliance purposes:
- Personal information, including name, date of birth, address
- Income and financial information to determine eligibility for premium tax credits and cost-sharing reductions
- Health information required for the evaluation of health insurance plans
- Any other information necessary for ACA enrollment and compliance
I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time in writing. I understand and agree to be enrolled successfully in an ACA-compliant health insurance plan by Monica Hunt or Affiliated agent or agency. I may revoke this consent at any time by providing written notice to Monica Hunt at monica.hunt16@gmail.com
I hereby certify that, to the best of my knowledge, the provided information is true and accurate.
I understand that I have the right to:
- Review and obtain a copy of this consent form
- Request a list of disclosures made using this consent.
- Revoke this consent at any time in writting
By signing this consent form, I give my permission to Monica Hunt or affiliated agents/agencies 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(s) 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:
Searching for an existing Marketplace application, 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, Providing ongoing account maintenance and enrollment assistance, as necessary, or 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 understand I will receive a 1095A and will need to file a IRS Form 8962 in order to reconcile any Advanced Premium Tax Credits.
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 monica.hunt16@gmail.com