Cindy | ACA Consent Form

Affordable Care Act (ACA)

Protection of Personally Identifiable Information (PII) Consent Form
Please Read and Sign Below

Centers for Medicare & Medicaid (CMS) Model Consent For Agents and Brokers
Agent On Record: Cindy L Zapata Agent NPN: 20866912

Contact:(956)640-0643 Email: CLZ.SerenityLife@gmail.com
Applicant*

Applicants First NameApplicants Last Name
Applicants Phone Number*
Please enter a valid phone number.
Email
example@example.com
Date of Consent*

MonthDayYear
Date
Signature*

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If you have already filled this information before you may skip the PII Form and click

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Si ya ha completado esta información antes, puede omitir el formulario de PII y hacer clic en

¡OBTENER COTIZACIÓN AHORA!
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Affordable Care Act (ACA)