Marketplace Consumer Consent Form


Marketplace Consumer Consent Form

Updated guidelines for current and new clients.

This form is giving consent for Susan Speidell (Agent/Owner) InsurWorks, LLC to do the following:

You are giving permission to Susan Speidell, (Agent) to serve as your health insurance agent or broker for yourself and your entire household if applicable for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace ( plans). By consenting to this agreement (typing your name below), you authorize Susan (Agent) to view and use the confidential information provided by you in writing, electronically, or by telephone only for the purposes of 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 other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums.

3. Providing ongoing account maintenance and enrollment assistance, as necessary; or

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

5. To review and confirm the accuracy of the eligibility application and provide a clear explanation of the client attestations at the end of the eligibility application.

I understand that Susan Speidell, (Agent) will not use or share my personally identifiable information (PII) for any purposes other than those listed above. Susan (Agent) will ensure that my PII is kept private and safe when collecting, 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 or by calling (414) 306-5309.

Please type your full name below in the fillable box to agree to these terms and conditions:

Primary Household Contact and/or Authorized Representative:

Primary Household Contact and/or Authorized Representative:

Susan Speidell (Agent)

NPN: 9080966


Please do NOT REPLY directly back to this email.

If you have any further questions email Susan directly.

Thank you!