I give my permission to Greg Diaz 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/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 payments of the premium tax credit 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 understand that I do not have to share additional PII or protected health information (PHI) with my Agent beyond what is required on the Marketplace 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 email, text or written letter.