Agent-Consent Hall Biddle and Associates, Inc Marketplace Agents and Brokers Consent Form OMB Control Number: 0938-1438 Expiration Date: 07/31/2028 I, the undersigned applicant, hereby give my permission to Hall Biddle and Associates, Inc, 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 and/or State Base. 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 and/or State Base application; 2. Completing an application for eligibility and enrollment in a Marketplace and/or State Base Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace and/or State Base premiums; 3. Providing ongoing account maintenance and enrollment assistance, as necessary; or 4. Full Authorization to speak on my behave regarding my Marketplace and/or State Base application, and responding to inquiries from the Marketplace and/or State Base regarding my application. 5. Complete my Hall Biddle and Associates Consumer Eligibility Review Form, and to be confirmed by me 6. If I have any updates to be made to my application during the year. It's will be my responsibility to notify Hall Biddle and Associates, by completing my Hall Biddle and Associates Health Insurance Update Form online at www. hallbiddle.com or call Hall Biddle and Associates on 888-529-0510 ext. 1 and let them know of the updates to be made to my application. I understand that the Agent will not use or share my personally identifiable information (PII) for any 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 and/or State Base 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, and I may revoke or modify my consent at any time by filling out the online revoke form at www.hallbiddle.com. Name of Primary Writing Agent(Required)(Click the dropped down and click the Writing Agent Name) Jerry HallAgent National Producer Number (last 4 digits)(Required)(Click the dropped down and click the the last 4 digits ) 5709Phone Number(Required)(Click the dropped down and click the phone number) (888)529-0510Agent Email Address(Required)(Click the dropped down and click the email address) jh@hallbiddle.comAgency Name:(Required)(Click the dropped down and click the Agency Name) Hall Biddle and Associates, IncAgency National Producer Number(last 4 digits)(Required)(Click the dropped down and click the last 4 digits) 3403Owner of Agency(Required)(Click the dropped down and click the owner of agency) Jerry HallPhone Number(Required)(Click the dropped down and click the phone number) (888)529-0510Email Address(Required)(Click the dropped down and click the email address) jh@hallbiddle.comName of Applicant and/or Authorized Representative:(Required)Applicant's Phone Number(Required)Applicant's Email Address(Required) Applicant's Signature(Required)Applicant's Signature Date MM slash DD slash YYYY PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938 1438. This information collection specifically details what information will be required to be collected and maintained by agents, brokers, and web-brokers were they to receive a request from HHS for consent records. This information collection will provide HHS with documentation that may be used for monitoring, audit, and enforcement activities. The time required to complete this information collection is estimated to take up to 10 minutes per applicant per year, which includes the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is pursuant to 45 C.F.R. §155.220(c)(5), which states that HHS or its designee may periodically monitor and audit an agent, broker, or web-broker under this subpart to assess its compliance with the applicable requirements of this section. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850, Attention: Information Collections Clearance Officer or email Brian Gubin at Brian.Gubin@cms.hhs.gov.
