This form is giving consent for Transition Health Benefits to do the following:
 ** If you are on Medicare please do not fill out this form**
You are giving permission to our agency to serve as your 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 (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.Â
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, texting us (262)784-7344 or by calling our agency at (262)784-7344. You only need to fill this form out 1 time per lifetime while working with THB.
THB Rockstar Team -Â Thank you for your business and referrals!
Todd Catlin            Kevin Truebenbach Â
NPN:Â 243806Â Â Â Â Â Â Â Â Â Â Â NPN:Â 2677788Â Â
262-439-4560Â Â Â Â Â Â Â Â Â Â Â 262-439-4570Â Â Â Â Â Â Â Â Â Â
todd@thbwi.com       kevin@thbwi.com    Â
Susan Cyr              Amanda McGinness
NPN:Â 6497712Â Â Â Â Â Â Â Â Â NPN:Â 7612989
262-439-4566Â Â Â Â Â Â Â Â Â Â 262-439-4568
susan@thbwi.com     amanda@thbwi.com
Sue Vermey            Monica Lopez
NPN:8396419 Â Â Â Â Â Â Â Â Â NPN: Pending
262-439-4781 Â Â Â Â Â Â Â Â Â 262-216-1023
svermey@thbwi.com    monica@thbwi.com
Tim Schappel          Megan Enerson       Â
NPN: 6506070Â Â Â Â Â Â Â Â Â Â NPN:Â 16588617 Â Â Â Â
262-439-4567Â Â Â Â Â Â Â Â Â Â 262-439-4569Â Â Â Â Â Â Â Â Â
tim@thbwi.com        megan@thbwi.com    Â
Kate Rodewald         Lana Bell             Â
NPN: pending          NPN: 20684099 Â
262-261-4224Â Â Â Â Â Â Â Â Â Â 262-216-1020Â Â Â Â Â Â Â Â Â Â Â
kate@thbwi.com       lana@thbwi.com       Â
Rae Anne Sheedy       Jan Kunkel
NPN: 9751494Â Â Â Â Â Â Â Â Â Customer Support
262-439-4563Â Â Â Â Â Â Â Â Â Â 262-439-4571
rae@thbwi.com        jan@thbwi.com
Jennifer Martin        Ben Zang
NPN:Â 18188099Â Â Â Â Â Â Â Â NPN: 19765641
262-439-4783Â Â Â Â Â Â Â Â Â 262-261-4223
Jennifer@thbwi.com   ben@thbwi.com
🔹All calls are recorded at Transition Health Benefits🔹
Call or text us at (262)784-7344
Thank you for your business and referrals!
Please type your name below.
