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Authorization and Consent Form

I give my permission to Jackson Cantey (“Agent or 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 or Agency to view and use the confidential information provided by me in writing, electronically, or by phone only for 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 advanced 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 application

I understand that the Jackson Cantey 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 secure 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 contacting my Agent.

Agent or Agency Name: Jackson Cantey

Agent or Agency Phone Number: 9842122345

Agent or Agency Email: [email protected]

Agent or Agency NPN: 20752290