Health Checklist

By signing below, you acknowledge the following:

I understand:

•It is my responsibility to review the Summary of Benefits for chosen plan(s).

•There is limited coverage for foreign travel under most policies. Other options
may be available.

•I should not cancel existing coverage until a new policy is officially approved.

•It is my responsibility to cancel prior insurance coverage. A company will not “back date” a cancellation request. I must take steps to make sure the prior policy was canceled, even if a representative of ISC assisted with the cancellation. ISC will NOT be notified of the cancellation of the prior policy.

•I understand that ISC typically does not receive copies of correspondence sent to me by the insurance company or the Marketplace. I will need to call or email my agent if I have questions about the correspondence I have received.

•It is my responsibility to work directly with the insurance company for any billing issues, including initial setup.

•I will need to make all payments directly with the insurance company.

•It is my responsibility to work directly with the insurance company regarding claims-related issues.

•I understand that ISC does not offer every plan available in my area. To get information on all of your options you may contact healthcare.gov or 1-800-318-2596.

•Email and text messages are not secure. I will not send confidential health or financial information via email or text message.

•If my plan has Provider Networks, it is my responsibility to verify that my doctors(s) and or facilities are in my network. If I go to a doctor or facility outside of my network, I understand that it is very likely there may not be coverage. 

•I understand, I need to pre-certify for surgery (including some outpatient procedures), hospitalization, and durable medical equipment.

•I understand, it is my responsibility to confirm that my current medications are on my plan’s drug list.

Privacy & HIPAA Notice. ISC uses secure, HIPAA-compliant software (such as HeathSherpa, JotForm HIPAA and Microsoft OneDrive) to collect and store your information. Other HIPAA-compliant services may be used in the future. By submitting this form, you consent to your PHI being securely handled and stored through such systems.

ACA Consent

{clientFirst} {lastName} give(s) permission to {yourAgents} 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 and associate agents/staff 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:

1. Searching for an existing Marketplace application;
2. 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;
3. Providing ongoing account maintenance and enrollment assistance, as necessary; or
4. Responding to inquiries from the Marketplace regarding my Marketplace application.
5. To review and confirm the accuracy of the eligibility application, as well as to provide a clear explanation of the client attestations at the end of the eligibility 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 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 contacting the agent or broker directly.or modify my consent at any time by contacting the agent or broker directly.