CMS Consent Form for Marketplace Agents and Brokers

I, , give my permission to Matthias Allred 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 to view and use the confidential information provided by me 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 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; or
  4. Responding to inquiries from the Marketplace regarding my Marketplace application.

I understand that the Agent will not use or share my personally identifiable information (PII) for 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. I may revoke or modify my consent at any time by emailing [email protected] or sending written correspondence to Skyline Insurance Agency.

Name of Primary Writing Agent: J Matthias Allred
Agent National Producer Number: 16559688
Phone Number: 801-396-8200
Email Address: [email protected]

Name of Primary Household Contact and/or Authorized Representative:
Phone Number:
Email Address:

Leave this empty:

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Signature Certificate
Document name: CMS Consent Form for Marketplace Agents and Brokers
lock iconUnique Document ID: 95c1535c1235452293642f052bcbea5e230de185
Timestamp Audit
August 16, 2023 9:40 pm MDTCMS Consent Form for Marketplace Agents and Brokers Uploaded by Matthias Allred - [email protected] IP
August 25, 2023 8:19 am MDTMaricar Gaspar - [email protected] added by Matthias Allred - [email protected] as a CC'd Recipient Ip:
October 12, 2023 1:22 pm MDTMaricar Gaspar - [email protected] added by Matthias Allred - [email protected] as a CC'd Recipient Ip: