I, Mr./Ms.. , am requesting assistance in enrolling in health insurance through the Health Insurance Marketplace. I have provided information necessary to be eligible for the Health Insurance Marketplace tax credit and to obtain reduced premium benefits.

I hereby give my permission to the agents and entities specified above to act as a health insurance agent or broker for me and my entire family, if applicable. By consenting to this agreement, I authorize them to view and use 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 and/or creating an application in the Insurance Marketplace;

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 me pay Marketplace premiums;

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

4. Respond to inquiries from the Marketplace regarding my Marketplace application.

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at any time by contacting the authorized agents and entities to receive an acknowledgment that the consent has been rescinded.

I further understand that in the event of any changes to the information provided below and/or other information, I must inform them immediately in order to update my application. 

Marital status:

Projected annual household income:

Number of persons on your tax return  

Persons with health coverage:

I confirm that I have NO other health insurance, as well as that I have no offer at my job of health coverage. 

I sign this consent under penalty of perjury, which means that I have provided true answers to all questions to the best of my knowledge. I know that I may be subject to penalties under federal law if I intentionally provide false information.