Consent
I give my permission to Man Ho (NPN: 17193508, email: manvanho@yahoo.com, phone: 813-514-3763) as my assisting agent,
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(healthcare.gov). 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;
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 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 text messages or email.
Review
I have reviewed the Marketplace eligibility application information and confirmed its accuracy prior to the application being submitted.
The agent explained the attestations at the end of the eligibility application to me prior to the application being submitted and I was
given an opportunity to ask questions about them.
