Health Insurance Consent & Confirmation Form

I give my permission to Ulness Health LLC, and any of its agents, to serve as the health insurance agent or broker for me 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 Agents 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 Agents will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agents will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.

Furthermore, 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 Agents 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 Ulness Health via either of the following methods:

• Phone: (920) 735-2852
• Email: [email protected]

I understand signing this consent form does not obligate me to enroll in a plan or use Ulness Health LLC as my agent.

With my signature below, I hereby consent to and confirm the above: