ACA Consent Form

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ACA Consent Form

Affordable Care Act Marketplace Enrollment Consent Form

I give my permission to Janice Grice 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. If I choose a carrier plan that Janice Grice is not contracted with, I give permission for my agent and Health Sherpa (and their affiliated agents) to assist me as needed with my application. 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 telephone only for the purposes of one or more of the following:

1. Searching for an existing Marketplace application;

2. 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;

3. Providing ongoing account maintenance and enrollment assistance, as necessary; or

4. 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 Janice Grice at janice@jgiadvisor.com with a written request.

Name of Primary Writing Agent: Janice Grice

Agent National Producer Number: 19964307

Phone Number: 940-213-1916

Email Address: janice@jgiadvisor.com

Name of Primary Household Contact and/or Authorized Representative

Phone Number

Email Address

By clicking "I Agree" you (1) acknowledge that you have read, understood and agreed to all of the above statements and (2) are giving Janice Grice, a licensed agent, CONSENT to assist and enroll you with your Marketplace coverage.

Agree

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