Consumer Authorization Form

The Department of Health and Human Services requires licensed sales agents to obtain consumer consent prior to providing assistance to Marketplace consumers.  By signing this form, you acknowledge that the agent has informed you of the functions and responsibilities of agents in the Marketplace, and grant permission to the authorized licensed sales agent to conduct the following activities:

  • Conduct a search for the consumer application through the Marketplace
  • Assist with completing an eligibility application
  • Assist with plan selection and enrollment.
  • Assist with ongoing account/enrollment maintenance 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 purpose 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 purpose above.

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Name
Marital status:
Address Change:
Phone number change:
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