ACA Marketplace Consumer Consent

Give your licensed specialist permission to help with your Marketplace coverage. Read the permissions, choose what you authorize, and keep your emailed copy.

1. Consumer information

Full name * State of residence * Coverage plan year *

Consent permits assistance; it does not establish Special Enrollment Period eligibility. Your specialist will verify any qualifying event and enrollment deadline separately.

Email for your copy * Confirm email * Phone * Date of birth (optional) Street address * City * ZIP * FCC report ID (optional) Who is signing? * Signer’s full name *

Required fields are marked *. Do not enter Social Security numbers, payment information, medical details or Marketplace passwords. Optional date of birth and FCC report ID are collected only with your consent when you submit.

5. Consent duration

Up to 12 months from signing, unless revoked or replaced earlier. Georgia consent also ends no later than December 31 of the selected coverage year. New consent is required for another coverage year. A shorter period ending on the date I choose.

6. Revoke or modify consent

Revoking consent stops future assistance; it does not automatically cancel your health coverage. Your consent record remains retained for required recordkeeping.

Georgia Access: initial consent and privacy

I give permission to the above-mentioned agent/agency to serve as the health insurance agent for myself and my entire household if applicable, for enrollment in a Qualified Health Plan offered on the Georgia State-based Exchange (Georgia Access). By consenting to this agreement, I authorize the above-mentioned agent/agency to view and use the confidential information, including personally identifiable information (PII), provided by me in writing, electronically, or by telephone only for the purpose of one or more of the following:

1. I give permission to access my information for the purpose of helping me complete an application for eligibility and enrollment in a Qualified Health Plan or other insurance affordability programs, such as Medicaid and PeachCare for Kids® (CHIP) or advance premium tax credits to help pay for insurance premiums. I understand that the agent/agency may search for and access my existing Georgia Access application, submit my completed application for review by Georgia Access, provide ongoing account maintenance, enrollment assistance, and respond to inquiries from Georgia Access regarding my application. I authorize the agent/agency to do so on my behalf.

2. I understand that the agent/agency will not use or share my personally identifiable information (PII) for any purposes other than those authorized through this consent. The agent/agency will ensure that my PII is protected when creating, collecting, disclosing, accessing, maintaining, storing, and using my PII for the stated purposes above. I understand that I am not required to share additional PII or protected health information (PHI) with the agent/agency beyond what is required for eligibility and enrollment purposes.

The named specialist, agency, NPNs and contact information are shown above. Your selected activities limit this authorization. Your electronic signature and submission date apply to both initial consent and privacy. Application review, tax-credit attestations and plan approval will be documented separately when applicable.

I have read and agree to the Georgia Access initial consent and privacy language above, limited to the activities and duration I selected.

7. Consumer signature

I agree to sign electronically and receive an emailed copy, including the personal information I enter. I can print/save my copy or request a paper copy without a fee. I may request a paper consent process before signing.Type your full signer name as your electronic signature *

Your signature date and time will be recorded automatically in Eastern Time. By selecting “Sign and submit consent,” you authorize only the permissions you selected. Your specialist’s verification and signature will be recorded separately.