I, (Primary Houshold Contact and/or Authorized Representative) give my permission to (The Applicable Agent/Broker), to serve as the health insurance agent/broker for me and my entire household, if applicable, for the purpose of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace (often referred to as “The Marketplace”, or “Healthcare.gov”, or “FFM”). 

I authorize him to view and use my/our confidential information provided by me electronically, in writing, or by phone for the sole purpose of estimating, proposing, setting up an account, enrolling, and servicing said account forthwith in the above mentioned Marketplace, Medicaid and/or CHIP determinations, determining advance tax credits to help pay for Marketplace premiums and to respond to inquiries from the Marketplace on my behalf.  My/our personal identifying information (PII) can only be used for the above purposes and will be safeguarded by said agent/broker according to FFM rules. 

I understand I do not have to share other personal or health information beyond the scope of what is required on any application for health insurance, as stated above. I grant this permission until such time I revoke it in writing, email, or text message to the agent/broker.