CMS Model Consent Form for Marketplace Agents and Brokers

I give my permission to Michael Kopek ("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. 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.  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 in writing 30 days in advance of the intent to revoke.

I give permission to Michael Kopek to reach out to me by email, SMS, and phone upon submission of this form.

Agent Name: Michael Kopek

Agent Email: [email protected]

Agent NPN: 16441409

Agent Phone: (772) 248-9381

Agent of Record Name: Adam Kirschner

Agent of Record NPN: 20523239