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ACA Marketplace Consent and Attestation

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I, , give my permission to Jose Martin NPN: 13361766 to act as my health insurance agent or broker for myself and my entire household if applicable.

By consenting to this agreement, I authorize the Agent mentioned above to view and use the confidential information provided by me in writing, electronically, or by telephone for the purposes of one or more of the following:

1.) Searching for an existing Marketplace application.

2.) 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.

3.) Providing ongoing account maintenance and enrollment assistance, as necessary.

4.) Responding to inquiries from the Marketplace regarding my Marketplace application.

The Agent will ensure that my personally identifiable information (PII) is kept private and secure when collecting, storing, and using my PII for the stated purposes above. The Agent will not use or share my PII for any purposes other than those listed above.

I confirm that the information I have provided for 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 for 365 days from the date of signing or until I revoke it, and I may revoke or modify my consent at any time by contacting 1st Choice Alliance at 786-766-1247.

I also confirm that I have reviewed the information on the eligibility application and attest that it is accurate.

Name of Writing Primary Agent: Jose Martin

Agent National Producer Number: 13361766

Phone Number: 786-766-1247

Email Address: info@1chq.com

Name of Primary Household Contact or Authorized Representative:

Phone Number:

Email:

Important Marketplace Emails: If the Marketplace has your email address, they’ll automatically send you important information, updates, and reminders about Marketplace enrollment. You can opt out of these communications at any time. To do this, click on the "unsubscribe" link in the footer of any Marketplace email.

Privacy and the use of your information: The Marketplace will keep your information private as required by law. Your answers on this form will only be used to determine eligibility for health coverage or help paying for coverage. The Marketplace will check your answers using the information in their databases and the databases of other federal agencies. If the information doesn't match, the Marketplace may ask you to send them proof. The Marketplace won't ask any questions about your medical history. Household members who don't want coverage won't be asked questions about citizenship or immigration status.

As part of the Marketplace application process, the Marketplace may need to retrieve your information from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security (DHS), and/or a consumer reporting agency. They need this information to check your eligibility for coverage and help paying for coverage if you want it and to give you the best service possible.The Marketplace may also check your information at a later time to make sure your information is up to date. The Marketplace will notify you if they find something has changed.

Learn more about your data, or view the Privacy Act Statement.

By continuing, you ( ) grant 1st Choice Alliance LLC. and your agent, Jose Martin, permission to access your Marketplace application.

You also agree to the following two statements:

1.) I agree to have my information used and retrieved from data sources for this application. I have consent for all people I’ll list on the application for their information to be retrieved and used from data sources.

2.) I understand that I'm required to provide true answers and that I may be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period if I qualify. If I don’t, I may face penalties, including the risk of losing my eligibility for coverage.

PLEASE NOTE: By submitting this form, you give us, 1st Choice Alliance, permission to send you emails, SMS/MMS, and calls.

Application Type:

Please Read The Following ACA Attestation:

I am signing this application under penalty of perjury, which means I've provided true answers to all the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information.

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11/09/2024 8:36 AM EDT

ACA Marketplace Consent and Attestation Uploaded by Joe Martin - customercare@1chq.com IP 98.219.64.224