Authorization and Consent
I authorize Insurance Matters LLC, a licensed Insurance Agency and its affiliates, employees, and agents permission 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. I also authorize Insurance Matters, LLC to change my agent of record to the agent listed below, and to continue to be my agent until notified in writing by me. By consenting to this agreement, I authorize Insurance Matters, LLC to view and use the confidential information provided by me in writing, electronically, or verbally 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, to keep coverage active as long as possible, including cancellation of preexisting or subsequent plans, until instructed otherwise.
Responding to inquiries from the Marketplace regarding my Marketplace application.
*Income Statement: I understand that Marketplace savings are based on my expected household income for the year I want coverage, not last year’s income. Income is counted for me, my spouse, and all claimed dependents on my federal tax return (if the dependents are required to file). Their income must be included even if they don’t need health coverage. If my estimated household income changes, I WILL notify the healthcare marketplace or Insurance Matters, LLC to avoid possible tax liabilities.
*Right to Cancel: The client has the right to revoke their consent given to Insurance Matters, LLC to process their application with the Healthcare Marketplace on their behalf at any time before processing. The client may also terminate their coverage with the insurance carrier at any time. Please check the box below stating you understand you can cancel at any time.
*Consent to contact: I give my permission for the above-mentioned entities/persons to contact me by email, phone, or text for the purposes of:
Further determining eligibility
Educating me on health and other insurance options
Review and/or sign documents for health-insurance
Obtain additional or updated information to ensure continued coverage
I agree to receive automated text messages from Insurance Matters, LLC with insurance updates, information about my policy, tips for getting the most out of my insurance, and renewal options. Message and data rates may apply. I understand that I can opt out at any time by replying STOP
*Responsibilites: I am responsible for:
- Notifying Insurance Matters LLC of any changes to my qualifying information
- Keeping information current
- Submitting requested proof to the Health Insurance Marketplace.
*Notice of privacy: 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 in writing.
Agency Contact Information:
Agent NPN: 20488722
Agency NPN: 21091155
Phone Number: 515-UMATTER (515-862-8837)
Email Address: agency@myinsurancematters.com
Mailing Address: PO Box 2281 Lexington, SC 29071