Marketplace Consent Form

This consent form outlines you rights. Please read it carefully.

As a licensed Health Insurance Broker, Cynthia Watson of Watson Agency, Inc. has completed the annual Affordable Care Act certification by the Marketplace in your state. With this yearly training, and an individual or family's formal consent, brokers are authorized to search for and assist households with their Marketplace account. The purpose of this form is to receive your informed written consent.

I, (primary household contact)

Name

give my permission to Watson Agency, Inc., and/or their staff to provide the following services on behalf of myself, and my entire household if applicable.

1. Search for an existing Marketplace application;

2. Completing an application for eligibility and enrollment in a marketplace Qualified Health Plan or government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace Premiums or enrollment in off-exchange insurance products as applicable.

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 Watson Agency, Inc. and/or their staff will not share my personally identifiable information (PII) and they will ensure that my PII is kept private and safe when collecting, storing, and using my information 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 my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time. I understand that requests must be made in writing, either by sending the request via certified mail to the address below or via email to CYNDI.WATSONAGENCY@gmail.com.

Agency Contact Information:

Watson Agency, Inc

269 W. Jackson St. Cicero, IN. 46034

Name of Primary Writing Agent: Cynthia S. Watson

IN License # 2082450

NPN # 1448615

Phone Number: 317-984-8191

Email Address: Cyndi.watsonagency@gmail.com

Name of Primary Household Contact and/or Authorized Representative:

Date of birth

Month

Day

Year

Zip Code:

I declare that the info I’ve provided is accurate and complete.

I understand that by clicking submit below, I am attesting that the information provided is true and correct to the best of my abilities.

I understand that by giving this authorization, I consent to have the broker access my data within my states designated exchange.

I understand that I may revoke access by request at ANY time directly with the Exchange without cause OR by emailing my request to my broker.

Signature

Signature field is empty.

Date of Signature:

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