Rev Oct 2025
I, [name of primary applicant], give my permission to
Amanda Sandoval ("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 or State Based 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 phone only for 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 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 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 and PHI 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 PHI 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 by contacting my Agent.
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.
Primary Writing Agent
Name of primary writing Agent: Amanda Sandoval
Agent National Producer Number: 21299424
Phone number: 956-365-9337
Email address: [email protected]
Rev Oct 2025