Agent: Ingrid Andersen-Pottinger
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).
I, (the undersigned) give my permission to INGRID ANDERSEN POTTINGER of CLEAR SOLUTIONS INSURANCE, INC. (“Agent”) to serve as the health insurance agent or broker for myself and my entire household if applicable, for the purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace/State-based Marketplace on the
Federal Platform. By providing my consent, I authorize the above-mentioned Agent to view and use the confidential information, including personally identifiable information (PII), provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following:
- Searching for an existing Marketplace application;
- 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 tax credits to help pay for Marketplace premiums;
- Providing ongoing account maintenance and enrollment assistance, as necessary; or
- Responding to inquiries from the Marketplace regarding my Marketplace 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 is protected when creating, collecting, disclosing, accessing, maintaining, storing, and using my PII for the stated purposes above.
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 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 emailing ([email protected] or texting (786-361-7575) my Agent.
If you authorize the Ingrid Andersen Pottinger of Clear Solutions Insurance, Inc (NPN 7313337) to assist you in the health insurance enrollment process, please TYPE your name AS YOUR SIGNATURE and date below.
Ingrid Andersen Pottinger, 786-361-7575, [email protected], NPN 7313337
Clear Solutions Insurance, Inc. NPN 17029353