Marketplace Consumer Consent Form

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Marketplace Consumer Consent Form

Updated guidelines for current and new clients working with our agency Transition Health Benefits.

This form is giving consent for Daniel Monahan: Transition Health Benefits to do the following:

You are giving permission to our agency to serve as your 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 (HealthCare.gov plans). By consenting to this agreement (typing your name below), I authorize the Agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of 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; or
🔹 Responding to inquiries from the Marketplace regarding my Marketplace 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 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 emailing dan@thbwi.com or texting/calling our agency at 414-426-8256.

Dan Monahan

NPN: 8353495 Phone: 414-426-8256

Email: dan@thbwi.com

By typing your full name below, you are giving consent for our agency for the above. If you have any questions or concerns please reach out directly to your agent. Enter you full name here:
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