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Consumer Consent Authorization

CMS requires health insurance agents to obtain a consumers consent prior to helping them apply for a subsidy and/or enroll in a Marketplace Qualified Health Plan (QHP). 

I, _______________________, give my permission to Eric Boutin  (“Agent”) to serve as the health insurance Agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by phone only for one or more of the following:

  • Searching for an existing Marketplace application

  • Completing an application for eligibility and enrollment in a Marketplace Qualified 

Health Plan 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 my application 

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

  • I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge.

  • I confirm that I have reviewed my completed application and that all information is accurate. 

  • I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by contacting my Agent or by revoking it through my HealthSherpa dashboard. 

Agent: Eric Boutin NPN: 7724950

Thank You

Marketplace Application Privacy Notice

 

We are authorized to collect personally identifiable information (PII) from you by Centers for Medicare & Medicaid Services (CMS). Any PII we collect is used to help you enroll in a Marketplace Qualified Health Plan (QHP) (and other related products you select, if applicable).

 

If you choose to give us PII, we may share this information with CMS and the insurer you select. CMS will maintain this information in a federal System of Records. PII is used or disclosed only under the following circumstances: in order to provide the services OHE is designed to offer – to compare insurance plans based on costs, benefits, and other important features; to determine eligibility for health coverage and cost-sharing reductions through HealthCare.gov; to choose a plan; and to enroll in coverage.

 

Providing your PII is voluntary. If you choose not to provide us with the PII requested, or not to respond to certain required HealthCare.gov questions, we will not be able to help you enroll in a QHP through the Marketplace. We recommend reaching out to the Marketplace Call Center directly at 1-800-318- 2596 (TTY: 1-855-889-4325) for further assistance in this scenario.

For more information, please review the CMS Privacy Notice on HealthCare.gov.

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