I, give my permission to: Tara Okhovatian with Covered by Tara

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. By consenting to this agreement, I authorize the above-mentioned Agent and/or a member of their Agency 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 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. I understand that the Agent or Agency will not use or share my
   personally identifiable information (PII) for any purposes other than
   those listed above. The Agent and Agency 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 my Agent.

I understand that this document is used to remain in compliance with CMS guidelines.

Email Phone

I hereby provide consent to the Agent and/Or Agency to Contact me for information concerning my health insurance needs via:
EmailText (msg)Phone

Income estimate given to Agent Date of Authorization

Signature

By clicking submit I agree that this document was signed by the person giving permission on this form , the information contained herein is correct and is intended to be used by the Assisting Agent/Agency as confirmation that I have read and understood the above document.