ACA Consent Form

Name

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Consent Form

Name (Required)

Phone (Required)

Email (Required)

Enter Email Confirm email

Please read the paragraph below before signing the form

I understand that the business and agent above will not use or share my personally identifiable information (PII) for any purposes other than for those which I have agreed. Illinois Health Agents Inc. and its Representatives 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 contacting Illinois Health Agents Inc. and its Representatives at any time by email help@ihealthagents.com or phone (312) 726-6565.

By signing below, you affirm that you have read, understand, and acknowledge the information included in your application and that you give the agent permission to begin working on your behalf in the marketplace. This permission includes the ability to:

1) Access my account, gather information, and update and act as the agent of record. 
2) Complete any existing or new application for eligibility for or enrollment into a health plan. 
3) Provide ongoing account maintenance or assistance as needed. I have reviewed my application.