By submitting this form, the individual identified below authorizes Brian Smith to act as their health insurance agent or broker. This consent applies to the individual and, if applicable, their entire household, for purposes related to enrollment in a Qualified Health Plan offered through the Federally Facilitated Marketplace.
With this authorization, the agent may:
- Access or search for an existing Marketplace application
- Complete applications for eligibility and enrollment in Marketplace Qualified Health Plans or government affordability programs such as Medicaid, CHIP, or premium tax credits
- Assist with ongoing account updates and enrollment needs
- Respond to Marketplace inquiries on the applicant’s behalf
The agent is permitted to use confidential information provided in writing, electronically, or over the phone solely for the actions listed above. Personally identifiable information (PII) will be handled securely and not used or disclosed for any other purpose.
The individual confirms that the information provided in the Marketplace application is accurate to the best of their knowledge. They are not required to share additional personal or health information beyond what is necessary for application and enrollment.
This consent will remain active unless revoked. Consent may be revoked or modified at any time by replying to this message with “I revoke my consent.”