By selecting an option below, each applicant consents to receive phone calls, Text and or emails from a HealthNetCO Insurance Agency licensed insurance agent regarding their products and services at the email address and phone number above, including wireless numbers if provided.
We understand that these calls may be generated using an automated technology. We are not required to grant consent as a condition of purchasing any property, goods or services.
Consumer Consent Form for Connect for Health Colorado’s marketplace Agents
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 on Connect for Health Colorado’s marketplace or Colorado Connect.
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:
- 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 afordability programs, such as Medicaid and CHIP+ or advance tax credits to help pay for insurance premiums.
- I understand that the agent may submit my completed application for review by Connect for Health Colorado and/or Colorado Connect, and I authorize them to do so on my behalf.
I agree that I have been informed and agree with all the disclaimers included in my exchange application.
- I agree that I have been informed and agree with all the disclaimers included in my exchange application.
- 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 Connect for Health Colorado’s marketplace portal and/or Colorado Connect portal, or by calling Connect for Health Colorado’s marketplace contact center at 1-855-752-6749.
- 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.
- 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.
VIEW PRIVACY POLICY