Revised for plan year 2023
The Centers for Medicare & Medicaid Services (CMS) requires health insurance agents, brokers, and web-brokers to document and ensure that the consumer or their authorized representative has reviewed and verified the accuracy of eligibility application information prior to submission.
You understand that:
Renewal of Coverage
Premium Tax Credit
Tax Attestations
Additional Attestations
By signing below, you acknowledge that:
By signing below, you authorize the agent to submit your reviewed and confirmed application to the Marketplace.
All of the agents listed below are licensed insurance agent/brokers authorized to sell life and health insurance in the state of Texas.
Use of Electronic Signatures: Each party agrees that this Review form and any associated documents may be electronically signed, and that any electronic signatures appearing on this Review form or associated documents are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.