Revised 09/2023

The Centers for Medicare & Medicaid Services (CMS) requires health insurance agents/brokers to obtain consumer consent prior to providing assistance to Marketplace consumers. By consenting to this agreement, you authorize the Agent(s) listed below to view and use the confidential information provided by you in writing, electronically, or by telephone only for the purposes of one or more of the following:

• Conducting a search for an existing consumer application using approved Classic Direct Enrollment (DE)/Enhanced Direct Enrollment (EDE) websites in the Marketplace,
• Helping complete an application for eligibility and enrollment in a Marketplace Qualified Health Plan (QHP) or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums,
• Providing ongoing account maintenance and enrollment assistance, as necessary,
• Responding to inquiries from the Marketplace regarding your Marketplace application.

Personally identifiable information (PII):

CMS authorizes agents and brokers to create, collect, disclose, access, maintain, store, and use specific data and personally identifiable information (PII). The information collected from you is used to help you with Marketplace enrollment, along with the other instances listed above.

You understand that the Agent(s) will not use or share your personally identifiable information (PII) for any purposes other than those listed above. The Agent(s) will ensure that your PII is kept private and safe when creating, collecting, disclosing, accessing, maintaining, storing, and using your PII for the stated purposes above.

Providing your PII is voluntary. You understand that you do not have to share additional personal information about yourself or your health with your Agent(s) beyond what is required on the application for eligibility and enrollment purposes. If you choose not to provide us with the PII requested or decline to answer questions on the Marketplace enrollment application, we will not be able to assist you in enrolling in a Marketplace QHP. Please visit Healthcare.gov or call 1-800-318-2596 (TTY: 1-855-889-4325) directly for further assistance if you choose not to provide consent or requested PII.

You confirm:

• The information you provide for entry on your Marketplace eligibility and enrollment application will be true to the best of your knowledge.
• Permission is granted to the listed Agent(s) below to serve as the health insurance agent or broker for yourself and your entire household, if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace.

Duration of Consent:

This consent will remain authorized unless you revoke, limit, or otherwise change your response. If you don’t make any limitations, exceptions, or changes to your consent now, you can still do so at any time in the future by notifying the Agent(s) below.

Use of Electronic Signatures: Each party agrees that this Consent form and any associated documents may be electronically signed, and that any electronic signatures appearing on this Consent form or associated documents are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

By signing below, you acknowledge that the Agent(s) informed you about the functions and responsibilities of agent/brokers within the Marketplace, and authorize the Agent(s) below to view and use the confidential information provided by you in writing, electronically, or by telephone only for the purposes of one or more of the previously stated instances above.

All of the agents listed below are licensed insurance agent/brokers authorized to sell life and health insurance in the state of Texas.