EmailMeForm
Health Insurance Marketplace Consent
Registered agents and brokers assisting consumers with the application for, and/or the enrollment into a Qualified Health Plan (QHP) through the Federally Facilitated Marketplace (FFM), MUST, per CMS guidelines, document consumer consent prior to accessing or updating consumer Marketplace information and other Personal Identifiable Information (PII) as provided in code 45 C.F.R. ยง 155.220
I/WE, {Enter Primary Applicants}
*
First
Last
Spouse or Domestic Partner
First
Last
Phone
*
###
-
###
-
####
Primary Email
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
give my/our permission to:
WCP Insurance Agency, LLC d/b/a My Policy Shop Insurance Agency and Frank Jude Fuss, Licensed Insurance Agent, and all downline properly licensed agents associated with this agency, 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:
-Searching 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 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 sending a written request by US Mail the agent or agency listed above to:
My Policy Shop
The Insurance Agency for
Health, Medicare Supplements, Life, and Retirement Security
3333 Evergreen Dr NE STE 220
Grand Rapids, MI 49525
*
YES, I agree
NO, I do not agree.
I need more information
Name of Primary Writing Agent: Frank Jude Fuss
Agent National Producer Number: 17396237
Phone Number: 616-914-4070
Email Address: Frank@MyPolicyShop.com
Name of Agency: WCP Insurance Agency, LLC
d/b/a My Policy Shop Insurance Agency
Agency National Producer Number: 18782156
Owner of Agency: Frank Jude Fuss
Phone Number: 616-914-4070
Email Address: Frank@MyPolicyShop.com
Please feel free to leave comments:
Signature of Primary Applicant
*
Clear
Signature of Spouse or Domestic Partner
Clear
