HEALTH INSURANCE

Marketplace Consent Form

Please complete the form below

CMS requires registered agents and brokers to document and obtain your consumer consent via this form prior to assisting you with Marketplace coverage. CMS Rules

First Name *

Last Name *

Phone *

Email *

Preferred Language *

Address *

City *

State *

Postal code *

Gender *

Date of birth *

What is your employment status? *

Are you currently on Medicare or Medicaid *

How much was your household income last year? *

$

What is your projected annual household income for this upcoming year? *

$

Do you currently have health insurance? *

Do you have a Primary Care Physician (Doctor) that you want to keep? *

Physician Full Name *

Name of Physician's Practice *

Physician's Practice Address *

Please Select your Marital Status *

Please enter your Spouse's First Name *

Please enter your Spouse's Last Name *

Please select your Spouse's Gender *

Please select your Spouse's Income *

Please select your Spouse's Date of Birth *

Do you wish to enroll your Spouse? *

Do you have tax dependents (typically children)? *

Number of Tax Dependents *

Enter Tax Dependent's information below

First Name *

Last Name *

Date of Birth *

Do you wish to enroll this dependent as well? *

Enter Tax Dependent's Information Below

First Name *

Last Name

Date of Birth

Do you wish to Enroll this dependent as well? *

Enter Tax Dependent's Information Below

First Name *

Last Name *

Date of Birth *

Do you wish to enroll this dependent as well? *

Enter Tax Dependent's Information Below

First Name *

Last Name *

Date of Birth *

Do you wish to enroll this dependent as well? *

Enter Tax Dependents Information Below

First Name *

Last Name *

Date of Birth *

Do you wish to enroll this dependent as well? *

Marketplace Consent Form

I give my permission to Alejandro Villasuso 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 emailing alejandro@avzbenefits.com.

I, Alejandro Villasuso, a licensed and experienced health insurance broker, hereby provide this attestation to acknowledge your agreement to the contents outlined below. By affixing your signature below, you respectfully request me or my agency affiliates to enroll both yourself and/or your family in the most suitable zero premium ACA plan available.

Please note that if there are no zero premium health plans available in your area based on the provided information, we will inform you of the available plans and seek your consent before proceeding with enrollment.

In addition to enrolling you in the optimal ACA plan, you authorize me or my agency to access your healthcare.gov account and submit the necessary information as required, in accordance with the details provided.

By signing below, you acknowledge the following:

You agree to the terms and conditions outlined in this attestation.

You respectfully request my expertise or that of my agency affiliates to enroll you and/or your family in the most suitable zero premium ACA plan available.

In the event that no zero premium health plan is available in your area, you understand that we will disclose the available plans and seek your consent before proceeding with enrollment.

You authorize me or my agency to access your healthcare.gov account and submit the necessary information as required.

Agent: Alejandro Villasuso, NPN: 16706152, 561-331-1289, alejandro@avzbenefits.com

Agency: AVZ Benefit Solutions, NPN: 17690527, 561-331-4658, info@avzbenefits.com

Enrollment Consent Agreement *

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