**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).
Authorization:
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:
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Searching for an existing Marketplace application;
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Completing an application for eligibility and enrollment in a marketplace Qualified Health Plan or advance tax credits to help pay for Marketplace premiums;
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Providing ongoing account maintenance and enrollment assistance, as necessary; or
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Responding to inquiries from the Marketplace regarding my Marketplace application.
Duration:
This authorization will last until I revoke it in writing, electronically, or by telephone
Privacy:
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.
Attestation:
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.
