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ACA Marketplace Consent Form

ACA Consent Form
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Registered agents and brokers assisting consumers apply for and enroll in Marketplace coverage must document consumer consent prior to accessing or updating their Marketplace information.

I give my permission to Brian Kelly, Agent/Broker, 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 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 email, call or text to my Agent/Broker/Assiter.

SMS Opt-in
By signing up via text, you agree to receive recurring automated marketing messages, including cart reminders, at the phone number provided. Consent is not a condition of purchase. Reply STOP to unsubscribe. Message frequency varies. Msg & data rates may apply. Your Privacy is our priority. Your information will not be shared.

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dISCLAIMER: Submission of your information constitutes permission for Brian Francis Kelly (Agent) to contact you with additional information about the cost and coverage details of health plans. Possible options include, but are not limited to Major Medical Plans, Short Term Plans, Fixed Indemnity Plans, and more. Descriptions are for informational purposes only and subject to change. Insurance plans may not be available in all states. For a complete description, please call 913-948-7504 to determine eligibility and to request a copy of the applicable policy.www.InsureVisors.com or Employee Benefits Partners is not affiliated with or endorsed by the United States government or the federal Medicare program. By using this site, you acknowledge that you have read and agree to the Terms of Service. and Privacy Policy.

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