• THIA Marketplace Eligibility Consumer Review

  • I, applicant, or the authorized representative, have reviewed and confirmed the accuracy of the eligibility information in the application. I authorize my agent to finalize and submit an application on my behalf for Marketplace coverage. This consent is only applicable to this application submission.
  • Agent Name: Aroona Zaeem
    Agent National Producer Number: 17040524
    Phone Number: 914-320-6628
    Email Address: azaeem@trianglehealthinsuranceagency.com
  • Name of Agency (if applicable): Triangle Health Insurance Agency
    Agency National Producer Number: 20337110
    Owner of Agency: Aroona Zaeem
    Phone Number: 914-320-6628
    Email Address: azaeem@trianglehealthinsuranceagency.com
  • Format: (000) 000-0000.
  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • The beneficiary is the person who will receive the insurance benefits. This form must be signed by either the beneficiary or an authorized representative acting for the beneficiary. Please sign your name and write the date.


    If you are signing as an authorized representative, list your relationship to the beneficiary below (for example: parent, spouse, or power of attorney).
    Do not list your insurance agent. The agent is not the beneficiary and not the authorized representative.

  • This authorization is a one-time authorization only for the submission of the current application to the Marketplace. Future application submission will require additional consent.

  • THIA Consent Form

  • , give my permission to Triangle Health Insurance Agency 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 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.

  • 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 Pll 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 emailing, calling, or sending a letter of revocation to Triangle Health Insurance Agency.
  • Name of Primary Writing Agent: Aroona Zaeem
    Agent National Producer Number: 17040524
    Phone Number: 914-320-6628
    Email Address: azaeem@trianglehealthinsuranceagency.com
  • Name of Agency (if applicable): Triangle Health Insurance Agency
    Agency National Producer Number: 20337110
    Owner of Agency: Aroona Zaeem
    Phone Number: 914-320-6628
    Email Address: azaeem@trianglehealthinsuranceagency.com
  • Format: (000) 000-0000.
  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • PRA DISCLOSURE: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX, expiration date is XX/XX/20XX. The time required to complete this information collection is estimated to take up to 0.08 hours per applicant per year, including the time to review instructions, gather the information needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure*** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Brian Gubin at Brian.Gubin@cms.hhs.gov.
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