Step 1 of 2 - Authorization for Agent Help

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  • I. Acknowledgement of Roles and Responsibilities of the AGENT (see Attachment A)

    I have been informed about and understand the Agent roles and responsibilities set forth on Attachment A and have been given the opportunity to discuss them with Gabrielle.

    II. Definitions and Explanations of Terms Used in This Form

    In this authorization form:

    - The words “I,” “me,” or “my” include my authorized representative if I have one.

    - Personally identifiable information is called “PII.” Examples of my PII include, but are not limited to my name, phone number, email address, home address, immigration status, income, and household size information.

    - Health plans available through the Marketplace are called Qualified Health Plans or “QHPs.”

    - Other programs called “insurance affordability programs” are also available through the Marketplace. These programs can help me or my family pay for health coverage, and include public programs, such as Medicaid or the Children’s Health Insurance Program (CHIP), premium tax credits, cost-sharing reductions, and, if one is available in my state, the Basic Health Program.

    III. Authorizations
    a. General Consent







  • I, ______________________, give my permission to Gabrielle Warner, to create, collect, disclose, access, maintain, store, and/or use my PII in order to carry out the following duties of a Agent, unless I have limited that consent as set forth in this document. I understand that Gabrielle Warner might need to create, collect, disclose, access, maintain, store, and/or use some of my PII in order to provide this assistance.

    1. Telling me about the full range of QHP options and insurance affordability programs for which I may be eligible, which includes: providing me with fair, accurate, and impartial information that assists me
    with submitting a Marketplace eligibility application; clarifying the distinctions among health coverage options, including QHPs; and helping me make informed decisions during the health coverage selection process. I understand that Gabrielle Warner might need to ask about and keep notes on my health coverage needs in order to help me.

    2. Helping me to apply for health coverage through the Marketplace.

    3. Helping me to enroll in a QHP.

    4. Ensuring that tools and help provided are accessible and usable for me if I have disabilities. If Gabrielle Warner can’t provide me with my accessibility needs, Gabrielle Warner will refer me the federal Marketplace Call Center, who can meet my specific needs. I understand that Gabrielle Warner might need to ask about and keep notes on any supports and services I need and might need to disclose my information to other assisters in order to help me.

    5. Providing me with this form and storing a signed copy of it.

  • IV. Exceptions or Limitations to Consent

    I understand that I can revoke, limit or otherwise change the consents I provide through this form at any time. If I don’t make any limitations, exceptions, or changes to my consents now, I can still do so at any time in the future by notifying Gabrielle Warner. I make the following exceptions, limitations, or changes:

  • V. Additional Information
    I understand that:

    1. I don’t have to provide Gabrielle Warner with any information that I do not want to provide. However, the help Gabrielle Warner provides is based only on the information I provide, and if the information given is inaccurate or incomplete, Gabrielle Warner may not be able to offer all the help that is available for my situation.

    2. I understand that Gabrielle Warner will ask me to provide only the minimum amount of my PII that is necessary to help me.

    3. Gabrielle Warner will make sure that my PII is kept private and secure when creating, collecting, disclosing, accessing, maintaining, storing, and/or using my PII. Gabrielle Warner will follow the privacy and information security standards that apply to them.

    4. If I give my contact information when signing this form, my general consent includes permission for Gabrielle Warner to follow up with me about applying for or enrolling into coverage after my first meeting with her.

    5. I understand that Gabrielle Warner is not required to help me in a language I understand under the CAC program rules, but Gabrielle Warner may be required by other federal, state, or local laws to provide these services to me. If Gabrielle Warner does not have the resources or skills to help me right away in a language I understand, he or she will refer me to the federal Marketplace Call Center, who can meet my specific needs sooner. If Gabrielle Warner needs to refer me to another source of help, he or she will refer me to the source that is easiest for me to access. I understand that Gabrielle Warner might need to share my contact information and information about my needs with possible referral sources in order to help me.

    6. I understand that once I have signed this authorization form, I can expect Gabrielle Warner to help me without asking me to sign another authorization form.

    7. Gabrielle Warner will provide me with a copy of my Authorization Form and this Attachment A

  • Attachment A: Roles and Responsibilities of Certified Agent/Broker

    1. Gabrielle Warner must tell me about the full range of qualified health plan (QHP) options and insurance affordability programs for which I may be eligible, which includes: providing me with fair, accurate, and impartial information that assists me with submitting a Marketplace eligibility application; clarifying the distinctions among health coverage options, including QHPs; and helping me make informed decisions during the health coverage selection process.

    2. Gabrielle Warner must help me to apply for health coverage through the Marketplace, if I want that help.

    3. Gabrielle Warner must help me to enroll in a QHP, if I want that help, but Gabrielle Warner can’t and won’t choose a plan for me.

    4. Gabrielle Warner must complete and receive a passing score in a Marketplace-approved training course before providing help to consumers, and must take additional training every year before being recertified by the organization to continue helping consumers.

    5. Gabrielle Warner must act in my best interests.

    6. Gabrielle Warner won’t discriminate against me based on my race, color, national origin, disability, age, sex, gender identity, or sexual orientation.

    7. Gabrielle Warner must ensure that tools and help provided are accessible and usable for me if I have disabilities. If Gabrielle Warner can’t provide me with my accessibility needs, Gabrielle Warner will refer me to the federal Marketplace Call Center, who can meet my specific needs.

    8. Gabrielle Warner must provide me with information about the roles and responsibilities of Agents/Brokers, including through this form.

    9. Gabrielle Warner must comply with Marketplace standards for keeping my PII private and secure, must obtain my consent before accessing my PII, and must permit me to revoke my consent at any time.

    10. Gabrielle Warner does not currently charge a fee for helping me. She is paid a standard commission by the insurance company I choose, providing I pay the monthly premium.

    11. Gabrielle Warner does not receive any funding, grants or payments from the government or the Marketplace for helping me with my application process.

    12. Gabrielle Warner won’t give me any gifts (including gift cards or cash) that are over $15 in value, or give me things that market or promote the products or services of another individual or business, as a way to persuade me to enroll in health coverage.

    13. Gabrielle Warner is not allowed to contact consumers to provide application or enrollment help by going door-to-door or otherwise contacting persons who have not already asked for help, unless Gabrielle Warner already has a relationship with a consumer, but Gabrielle Warner can go door-to-door or contact persons who have not already asked for help when providing general outreach and education to the public. Because I have a relationship with Gabrielle Warner, Gabrielle Warner is allowed to come to my door and/or to call me directly to provide application or enrollment help, so long as Gabrielle Warner follows other laws that might apply to that activity.

    14. Gabrielle Warner is not allowed to make “robo-calls” to consumers (by using an automatic dialing system or pre-recorded or artificial voice) unless Gabrielle Warner already has a relationship with the consumer. Because I have a relationship with Gabrielle Warner, Gabrielle Warner is permitted to contact me using “robo-calls” so long as Gabrielle Warner follows other laws that might apply to that activity.

    15. Gabrielle Warner must also meet any applicable state and local requirements when providing services to me.