Consent in English

My Rights as a Patient

By signing this form, I give consent to Please Select from Please Select to serve as the health insurance agent or broker, as my Agent of Record, for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace.

By signing this form, I give my permission to Please Select, and/or their staff to provide the following services on behalf of myself, and my entire household if applicable to keep my application and health coverage in good standing:

  1. Search for a new or existing Marketplace application;
  2. Completing an application for eligibility and enrollment in a marketplace Qualified Health Plan or government insurance affordability programs, such as Medicaid and CHIP, Marketplace Direct Enrollment Classic/Enhanced Direct Enrollment websites, or advance tax credits to help pay for Marketplace Premiums or enrollment in off-exchange insurance products as applicable.
  3. Providing ongoing account maintenance, enrollment assistance, information on plan benefits, new products, the benefits of new products, and payment transactions as necessary; or
  4. Responding to inquiries from the Marketplace regarding my Marketplace application; or
  5. Contact me by phone or by any written means to assist me or remind me of any action necessary to keep my policy in good standing.

I understand that I have the right to revoke this authorization, in writing, at any time. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party via email at:

I understand that my Agent of Record will maintain documentation stating that I and/or my authorized representative REVIEWED AND CONFIRMED THAT MY APPLICATION INFORMATION IS CORRECT AND ACCURATE as required by the Centers for Medicare & Medicaid Services (CMS) for eligibility and enrollment (45 C.F.R § 155.220(j)(2)(ii)(A)(1)-(2)).

I understand that the information I provide to my Agent of Record will be used or disclosed ONLY to provide information or assist me with or facilitate enrollment through a Federally-Facilitated Exchange or assist me in applying for advance payments of the premium tax credit (APTC) and cost-sharing reductions (CSRs) for QHPs, including prior to searching for a current application using an approved Classic Direct Enrollment (DE) or Enhanced Direct Enrollment (EDE) website.

I understand that a copy of this authorization will be available upon request from the Center for Medicare and Medicaid Services as required.

This includes maintaining documentation of the consumer’s or their authorized representative’s consent to the enrollment (45 C.F.R. § 155.220(j)(2)(iii)(A)-(C)). This also includes maintaining documentation stating a consumer or their authorized representative has reviewed and confirmed their application information is accurate (45 C.F.R § 155.220(j)(2)(ii)(A)(1)-(2)).

I understand that my Agent of Record will not use or share my personally identifiable information (PII) for any purposes other than those listed above. Additionally, my Agent of Record will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above. 

“We thank the agents for their dedication to providing exceptional service and helping consumers access coverage,” said Ellen Montz, Director of the Center for Consumer Information and Insurance Oversight within CMS, which oversees the Marketplace. “Agents and brokers are important partners to CMS in our shared goal of helping expand access to coverage across the nation.”