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Federally-Facilitated Marketplace (FFM) 
Consent form

**Updated September 2023 to comply with the 2024 plan year requirements

The Centers for Medicare and Medicaid Services (CMS) requires health insurance agents and brokers to obtain a customer’s consent prior to helping them apply for a subsidy and/or enroll in a Marketplace Qualified Health Plan (QHP).


By filling out this form I authorize Roger and/or Gina Masterson and Masterful Solutions, LLC to view and use the confidential information provided by me - for myself and for those on my application - in writing, electronically, or by telephone only 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 advance tax credits to help pay for Marketplace premiums; 

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

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



This authorization will last until I revoke it in writing, electronically, or by telephone


I understand the broker will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The broker 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 broker beyond what is required on the application for eligibility and enrollment purposes.

I am requesting the following assistance (select one)
Select an option as an e-signature

Thanks for submitting!

For those that love legal detail

Roger and Gina Masterson are authorized by Centers for Medicare and Medicaid Services (CMS) to collect personally identifiable information (PII) and personal health information (PHI) from you about you and your family members (if applicable).

By clicking the submit button you have authorized Roger and Gina Masterson to collect PII and PHI to help you enroll in a Marketplace Qualified Health Plan (QHP) (and other related products you select, if applicable).

If you choose to give us PII and PHI, we may share this information with CMS and the insurer you select. CMS will maintain the PII in a federal System of Records and the insurer will keep the information secure using their own privacy practices.

PII and PHI is used or disclosed only under the following circumstances:

  1. to provide the services we are authorized to offer

  2. to compare insurance plans based on costs, benefits, and other important features

  3. to determine eligibility for health coverage and cost-sharing reductions through

  4. to choose a plan and

  5. to enroll in coverage.

Providing your PII and PHI is voluntary. If you choose not to provide us with the PII and PHI requested, or not to respond to certain required questions, we will not be able to help you enroll in a QHP through the Marketplace. In that instance we recommend reaching out to the Marketplace Call Center directly at 1-800-318-2569 or further assistance.

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