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YES! I agree to the consent. Please help me with my GA Access Account.

Georgia Consent Form for Assistance with Marketplace Health Plans

I give my permission to FFM Agent Laura Bass NPN 17627675 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/State-based Marketplace on the Federal Platform. By providing my consent, 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 purposes of one or more of the following:
1. Searching for an existing Marketplace or GA Access application;
2. Completing an application for eligibility and enrollment in a Marketplace or GA Access Qualified Health Plan or an application for government insurance affordability programs, such as Medicaid and CHIP or advance payments of the premium tax credit 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, income or 1095A Retrieval;
5. Act as exclusive Agent of Record for Marketplace or State Based Exchange.
I understand that the agent/agency will not use or share my personally identifiable information (PII) for any purposes other than those listed above. 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 do not have to share additional PII or protected health information (PHI) with my Agent/Agency beyond what is required on the Marketplace application for eligibility and enrollment purposes. I understand that my consent remains in effect until a duration of ten years, and I may revoke or modify my consent at any time by contacting Primary Writing Agent: Laura Bass NPN 17627675 Phone Number: 615-843-0572 Email Address: [email protected]
Name of Primary Writing Agent: Laura Bass
Agent National Producer Number: 17627675
Phone Number: 615-843-0572
Email Address: [email protected]
Assistant Writing Agent: Michael Bennett NPN 8790924
I confirm that the information I provide for my Marketplace 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 also understand it is my duty to notify the agent or Marketplace / State Based Exchange if my income changes. Once an eligibility application is submitted, my stated income will be listed on the eligibility notice. If my income or tax filing changes, I understand I must contact my agent or Marketplace / State Based Exchange immediately to update the income status on my eligibility application.
I understand that my consent remains in effect until I revoke it. I may revoke or modify my consent at any time by emailing my agent. It is my duty to notify Laura Bass if I decide to work with another agent. Laura Bass cannot be held responsible for application changes performed by another agent or policy changes that occur without his assistance.
I understand that an annual review is advised, so the Agent can help me review potential income or tax filing changes and potential changes to plan offerings.
Free Service: I understand there is no cost associated with utilizing the assistance of a Marketplace / State Based Exchange Agent.
Cancellation: You are welcome to cancel your Marketplace OR State Based Exchange plan at any time by calling the number on your insurance card. Termination dates cannot be backdated.
No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All other categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.
OPT IN CONSENT: By submitting your phone number, you are authorizing Laura Bass to send you text messages and notifications. Message/data rates apply. Reply STOP to unsubscribe to a message sent from us.
PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1438. This information collection specifically details what information will be required to be collected and maintained by agents, brokers, and web-brokers were they to receive a request from HHS for consent records. This information collection will provide HHS with documentation that may be used for monitoring, audit, and enforcement activities. The time required to complete this information collection is estimated to take up to 10 minutes per applicant per year, which includes the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is pursuant to 45 C.F.R. §155.220(c)(5), which states that HHS or its designee may periodically monitor and audit an agent, broker, or web-broker under this subpart to assess its compliance with the applicable requirements of this section. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850, Attention: Information Collections Clearance Officer or email Brian Gubin at [email protected].