Agent First & Last Name: Ana Del Angel

CMS requires health insurance agents to obtain a customer’s consent prior to helping them apply for a subsidy and/or enroll in a Marketplace Qualified Health Plan (QHP). If you authorize the above named agent to assist you in the health insurance enrollment process, please provide your name, date, and signature below.

We are authorized to collect personally identifiable information (PII) from you by Centers for Medicare & Medicaid Services (CMS). Any PII we collect is used to help you enroll in a Marketplace Qualified Health Plan (QHP) (and other related products you select, if applicable).

If you choose to give us PII, we may share this information with CMS and the insurer you select. CMS will maintain this information in a federal System of Records. PII is used or disclosed only under the following circumstances: in order to provide the services HST is designed to offer – to compare insurance plans based on costs, benefits, and other important features; to determine eligibility for health coverage and cost-sharing reductions through HealthCare.gov; to choose a plan; and to enroll in coverage. Providing your PII is voluntary. If you choose not to provide us with the PII requested, or not to respond to certain required HealthCare.gov questions, we will not be able to help you enroll in a QHP through the Marketplace. We recommend reaching out to the Marketplace Call Center directly at 1-800-318- 2596 (TTY: 1-855-889-4325) for further assistance in this scenario. For more information, please review the CMS Privacy Notice on HealthCare.gov