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Key Acknowledgements by Signing this Consent Form:

 

• Your Selected agent/broker may have permission to Conduct a search for consumer applications using approved Classic DE/EDE websites in the Marketplace.

 

o Assist with completing an eligibility application.

 

o Assist with plan selection and enrollment.

 

o Assist with ongoing account maintenance.

 

• Consumer Personally Identifiable Information (P.I.I.)o Examples of P.I.I. include but are not limited to, Name, Date of Birth, Phone Numbers, Age, Medical Information, Social Security Number, Tax Information, Income, Street Address, Email Address etc...

 

o Agent will only ask for the minimum amount of P.I.I. necessary for them to carry out their functions and responsibilities o Consumer can revoke consent with agent present at any time.

 

o The agent will continue to protect any previously obtained P.I.I. information in the event of revocation of consent by a consumer or in the event of agent’s relationship with CMS being terminated.

 

Supplemental/Ancillary Products:

 

The agent has permission to speak to the consumer about life/ancillary products that can help to negate a consumer’s Out of Pocket expenses regarding their marketplace plan. These products are not related to the marketplace and enrollments can be completed at any time throughout the year.

 

Privacy Notice Statement:

 

By law, CMS requires agents to obtain certain forms of personally identifiable information for the purpose of comparing information provided on the application to the applicant’s income, residency status, and citizenship status among other things to assist in determining the applicant’s eligibility for Subsidies (assistance with paying monthly premiums). P.I.I. will only be disclosed and used by government entities like CMS and are protected by the agent. It is voluntary for a consumer to disclose any P.I.I. to agents or CMS directly. However, in the case of non-disclosure the agent/broker will not be able to help the consumer with picking and enrolling in a marketplace plan. The agent is not able to give any tax or legal advice in their capacity as an agent.