The Centers for Medicare & Medicaid Services (CMS) requires licensed sales broker to obtain consumer consent prior to accessing or updating the consumer’s Marketplace information. This informs you of the functions and responsibilities of the licensed sales broker in the Marketplace and grants permission to the authorized licensed sales broker to conduct the following activities:

1. Search for an existing Marketplace application.

2. Complete 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. Provide ongoing account maintenance and enrollment assistance, as necessary.

4. Respond to inquiries from the Marketplace regarding my Marketplace application.

You grant permission to John Dennis to serve as the health insurance broker for yourself and your entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, you authorize the above-mentioned broker 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 above. You understand that the broker will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The broker will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above. You confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. You understand that you do not have to share additional personal information about myself or my health with my broker beyond what is required on the application for eligibility and enrollment purposes. You understand that my consent remains in effect until you revoke it, and you may revoke or modify your consent at any time in writing.