I agree to terms & conditions provided by the company. By providing my

phone number, I agree to receive text messages from the business.

CMS requires health insurance agents to obtain a customer’s consent prior to

helping them apply for a subsidy and/or enroll in a Marketplace QualiDed Health

Plan (QHP). If you authorize the above named agent to assist you in the health

insurance enrollment process, please provide your name, date, and signature

below.

Marketplace Application Privacy Notice

We are authorized to collect personally identiDable information (PII) from you by

Centers for Medicare & Medicaid Services (CMS). Any PII we collect is used to

help you enroll in a Marketplace QualiDed Health Plan (QHP) (and other relatedproducts you select, if applicable).

If you choose to give us PII, we may share this information with CMS and the

insurer you select. CMS will maintain this information in a federal System of

Records. PII is used or disclosed only under the following circumstances: in

order to provide the services HST is designed to offer – to compare insurance

plans based on costs, beneDts, and other important features; to determine

eligibility for health coverage and cost-sharing reductions through

HealthCare.gov; to choose a plan; and to enroll in coverage. Providing your PII is

voluntary. If you choose not to provide us with the PII requested, or not to

respond to certain required HealthCare.gov questions, we will not be able to help

you enroll in a QHP through the Marketplace. We recommend reaching out to the

Marketplace Call Center directly at 1-800-318- 2596 (TTY: 1-855-889-4325) for

further assistance in this scenario.

For more information, please review the CMS

Privacy Notice on HealthCare.gov

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