Agent Broker Consent Form

Hall Biddle and Associates, Inc

Marketplace Agents and Brokers Consent Form

OMB Control Number: 0938-1438 Expiration Date: XX/XX/20XX

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 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. Full Authorization to speak on my behave regarding my Marketplace application, and responding to inquiries from the Marketplace regarding my Marketplace application.

5. Complete my Hall Biddle and Associates Consumer Eligibility Review Form and sign my name.

6. Complete my Hall Biddle and Associates Health Insurance Update Form and sign my name.

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 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 https://hallbiddle.com

Name of Primary Writing Agent(Required)
(Click the dropped down and click the Writing Agent Name)

Agent National Producer Number (last 4 digits)(Required)
(Click the dropped down and click the the last 4 digits )

Agent Phone Number(Required)
(Click the dropped down and click the the phone number)

Agent Email Address(Required)
(Click the dropped down and click the email address)

Agency Name:(Required)
(Click the dropped down and click the Agency Name)

Agency National Producer Number(last 4 digits)(Required)
(Click the dropped down and click the last 4 digits)

Owner of Agency(Required)
(Click the dropped down and click the owner of agency)

Phone Number(Required)
(Click the dropped down and click the phone number)

Email Address(Required)
(Click the dropped down and click the email address)

Name 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: 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, expiration date is XX/XX/20XX. The time required to complete this information collection is estimated to take up to 0.17 hours per applicant per year, including the time to review instructions, gather the information needed, and complete and review the information collection. 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, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. CMS Disclosure Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Brian Gubin at Brian.Gubin@cms.hhs.gov