I, , authorize the agent, , to provide my personal demographic information to the broker Sonia Beato, who will act as the health insurance broker for me and all members of my household, if applicable, for the purpose of enrolling in a subsidized or unsubsidized health plan based on my income and in accordance with the eligibility requirements established by the Affordable Care Act (ACA).
By accepting this agreement, I authorize broker Sonia Beato to view and use the confidential information I provide—whether in writing, electronically, or by phone—exclusively for the purposes of eligibility determination, enrollment, and Marketplace-related activities.
I have reviewed the information in the Marketplace eligibility application and confirmed its accuracy prior to submission. The broker explained the attestations at the end of the application, and I was given the opportunity to ask questions and receive clarifications.
I understand that the broker will not use or share my personally identifiable information (PII) for any purpose other than those for which I have given explicit consent. The broker will take all necessary steps to ensure that my PII remains private and secure when creating, collecting, disclosing, accessing, maintaining, storing, and using my information for the purposes I have authorized.
I also authorize agent to assist in the enrollment process and to access my personally identifiable information (PII) solely for the purpose of supporting the broker in the following functions:
I further understand that I am not required to share additional PII or protected health information (PHI) beyond what is necessary to determine eligibility and enrollment in the Marketplace.
I declare that I currently do not have other health insurance coverage and do not have an offer of coverage through my employer.
This consent remains valid until I revoke it. I understand that I may revoke or modify my consent at any time by sending written notice to: sbeato@1keyinsurance.net
Primary Broker:
Name Agent: Sonia Beato
Agent National Producer Number: 3664315
Phone Number: +1 (786) 222 9996
Email Address: sbeato@1keyinsurance.net
Authorized Assistant:
Name:
Agent National Producer Number:
Phone Number:
Email Address:
Primary Household Contact and/or Authorized Representative:
Name:
Phone Number:
Email Address:
