Online Enrollment Tool

Health Insurance

Consent for Assistance w/ Health Insurance

New government regulations require that you give us permission to assist you in acquiring health insurance. This includes giving us permission to access your information on the federal health insurance marketplace. You can also use this form to rescind (cancel) the right for us to assist you. Please complete this form and submit so that we may assist you in this process. Generally, this form is valid for 12 months from the date of submission.

Name*

Give Permission to*

Agreement*

I give my permission to the above listed 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 phone only for one or more of the following:

-Searhing for an existing Marketplace application

-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

-Providing ongoing account maintenance and enrollment assistance, as necessary

-Responding to inquiries from the Marketplace regarding my 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 contacting my Agent or by revoking it through this form.

I agree

E-Mail Address*

Repeat E-Mail Address*

Phone Number*

Date*

Rescind Permission

Yes, I no longer need your assistance
No, N/A - Please continue to assist me

English & Spanish Versions

Looking for health insurance?

HealthSherpa Quote & Enrollment Platform

(English & Spanish Version)

AgentExpress Quote & Enrollment Platform

(Multiple Languages Available)

We offer two quote and enrollment platforms because sometimes there can be a technical issue with one but not the other...generally, both are excellent platforms that offer an enhanced direct enrollment process that is faster and easier than going on healthcare.gov.

Both platforms make it easy for you to come back and upload any required documents or to perform other account maintenance tasks.

Some key notes:

Household Size: Count all dependents and spouse - even if one or more of them are not looking for coverage.

Household Income: Most types of income must be accounted for, including social security benefits. This is needed to calculate any subsidy/tax credit eligibility.

If you have questions or need help - please contact us!

Call 847-668-9194

PII & PRIVACY NOTICE STATEMENT

We are authorized to collect personally identifiable information (PII) from you by the Centers for Medicare and Medicaid Services (CMS). Any PII we collect is used to assist you in the enrollment process for health insurance or other qualifying insurance.

If you choose to give us PII, we may share this information with internal clerical staff, staff of intermediaries, and other personnel as required to complete your enrollment. PII is used or disclosed only under the following circumstances: in the insurance application process, assistance in payment processing, and when required to complete a task as directed by you.

The request to collect PII is voluntary under applicable laws. If you choose not to provide us with the PII requested, or not to respond to certain questions, we may not be able to assist in your enrollment process or to solve any issues that need to be addressed.

PII that is provided will be submitted to CMS (a federal agency) and will be maintained in a federal System of Records.

Attention: This website is operated by Insuringmyself.com LLC and is not the Health Insurance Marketplace website. In offering this website, Insuringmyself.com LLC is required to comply with all applicable federal laws, including the standards established under 45 CFR §155.220(c) and (d) and standards established under 45 CFR §155.260 to protect the privacy and security of personally identifiable information. This website may not display all data on Qualified Health Plans being offered in your state through the Health Insurance Marketplace website. To see all available data on Qualified Health Plan options in your state, go to the Health Insurance Marketplace website at www.healthcare.gov.