ACA CONSENT FORM

I {inputs.names},  am giving Consent to the Agent Moses O Adedipe: NPN 14991254 and Agency or any licensed Agent representing Mercyland Insurance Depot NPN:16395993 today {inputs.datetime}

The agent or Agency representatives will be assisting me in the following categories until the Expiration 12/31/2024.

• Searching for an existing Marketplace application.
• Assisting with completion of a Marketplace application for eligibility.
• Assisting with plan selection and enrollment.
• Assisting with ongoing account maintenance.
• Changing of NPN number so he will retain AGENT of RECORD for my policy.

As my producer of record, he will have access to my Protected Health Information (PHI) related to insurance support functions, such as membership maintenance, plan benefit information, transactionsactional information, new product information, enrollment, and disenrollment.

By signing this form, I confirm the producer listed above did significantly assist me with my enrollment in a Marketplace Health Plan. Additionally, by signing this form.

I understand any producer currently designated on my policy will be removed and the new producer being added will remain in effect until revoked or replaced in writing.

This consent does not authorize the producer listed above to speak with the Marketplace call center regarding an application. I will need to provide a separate authorization to the Marketplace call center to allow the producer access to my account information on my behalf.

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 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 in writing.

I understand that the printed name and electronic date stamp take the place of my signature on this form.

By contacting Mercyland Insurance Depot for assistance in obtaining health insurance you agree that we may create, collect, disclose, access, maintain, use, and store Personally Identifiable Information (PII), and PII for you or anyone else who is included on your application, to perform the following duties:

Inform you or your authorized representative about the full range of Marketplace health coverage options and insurance affordability programs for which you are eligible.

Mercyland Insurance Depot will:

• Assist you in completing your application for health coverage in a Qualified Health Plan (QHP) through the Marketplace and for insurance affordability programs.
• Help you enroll in a QHP or in an insurance affordability program.

You may revoke this authorization at any time and agree to notify us in writing if you choose to revoke this authorization.

Please note that Swanson-Phillips & Associates will be compensated by the insurance carrier if you choose to purchase coverage.

You are responsible for the selection of the insurance carrier that best meets your needs.

We will follow privacy and information security standards when creating, collecting, disclosing accessing, maintaining, storing, or using your PII.  Information about these standards is available at www.mercylandinsurance.com We are not expected or required to maintain or store any of your PII, but if we do maintain or store your PII, we will follow these privacy and information security standards.

You are under no obligation to provide any information to us, but we cannot provide coverage or services without the information we request.

AGENT INFORMATION

BROKER NAME: MOSES ADEDIPE

BROKER NPN: 14991254

AGENCY: MERCYLAND INSURANCE DEPOT

AUTHORIZATION TO COLLECT PERSONAL INFORMATION

By contacting Mercyland Insurance Depot for assistance in obtaining health insurance you agree that we may create, collect, disclose, access, maintain, use, and store Personally Identifiable Information (PII), and PII for you or anyone else who is included on your application, to perform the following duties:

Inform you or your authorized representative about the full range of Marketplace health coverage options and insurance affordability programs for which you are eligible.

Mercyland Insurance Depot will:

• Assist you in completing your application for health coverage in a Qualified Health Plan (QHP) through the Marketplace and for insurance affordability programs.
• Help you enroll in a QHP or in an insurance affordability program.

You may revoke this authorization at any time and agree to notify us in writing if you choose to revoke this authorization.

Please note that Swanson-Phillips & Associates will be compensated by the insurance carrier if you choose to purchase coverage.

You are responsible for the selection of the insurance carrier that best meets your needs.

We will follow privacy and information security standards when creating, collecting, disclosing accessing, maintaining, storing, or using your PII.  Information about these standards is available at www.mercylandinsurance.com We are not expected or required to maintain or store any of your PII, but if we do maintain or store your PII, we will follow these privacy and information security standards.

You are under no obligation to provide any information to us, but we cannot provide coverage or services without the information we request.

AGREE.

Privacy & Use of Information

We will keep your information private as required by law. The information we request will only be used to determine eligibility for health coverage and for applying for help paying for coverage. We may check your answers using the information in our databases and the databases of various federal agencies. If the information doesn’t match, we may ask you to send us proof. We won’t ask any questions about your medical history. You may voluntarily choose to share information on your medical history if you feel it would be helpful in making the right choice of coverage options. Household members who don’t want coverage won’t be asked questions about citizenship or immigration status.

As part of the application process, the Marketplace may need to retrieve your information from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security (DHS), and/or a consumer reporting agency. They need this information to check your eligibility for coverage and help paying for coverage and to give you the best service possible. We may also check your information in the future to make sure your information is up to date.

 It is your responsibility to inform the marketplace if the information used to obtain coverage or a subsidy change.  You are responsible for submitting the required information with your tax return to account for your subsidy each year.  Failure to do this may result in the denial of future tax subsidies. 

The Agent of Record for

Mercyland Insurance Depot is:

Moses O. Adedipe

Licensed Agent

NPN 14991254

Phone: 832-402-0733

I have reviewed the completed form for accuracy. and I have made sure all information is legible and correct. I also read and agree to the Privacy Policy of Mercyland Insurance Depot