Consumer Consent Form for Georgia Access

Consumer Consent Form for Georgia Access

This form is required by the State of Georgia for all agents assisting consumers with health coverage through Georgia Access. Completion and signature of this form are mandatory before an agent may legally act on behalf of a consumer. This consent complies with all applicable federal and state privacy laws, including HIPAA. Gennadii Zolotov is a licensed, independent insurance agent and not affiliated with the State of Georgia.
Consumer Name:*

First NameLast Name
Date of Birth*

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Date
Document Type*
Document Number*
Agent/Agency Name:

First NameLast Name
NPN:
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.
Primary Household Contact/Authorized Representative

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2. I understand that the agent may submit my completed application for review by Georgia Access, and I authorize them to do so on my behalf.
Primary Household Contact/Authorized Representative

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3. I agree that I have been informed and agree with all the disclaimers included in my exchange application.
Primary Household Contact/Authorized Representative

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4. I understand the plan(s) I am being enrolled in and agree that I wish to be enrolled in that plan; Iunderstand that I may cancel the delegation at any time either within the Georgia Access portal, acertified partner portal, or by calling the Georgia Access contact center at 1-888-687-1503.
Primary Household Contact/Authorized Representative

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Consent Duration: This consent form is valid for up to one (1) year from the date of the last signature provided above, unless it is revoked or replaced earlier by the consumer.
Primary Household Contact/Authorized Representative

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5. Optional: I give the agent only OR agent and any member of their 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 this consent, but if I do not, I will need to document a new consent every time I require future assistance from my agent.
Primary Household Contact/Authorized Representative

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