HC.gov Marketplace Consent Form
This notice must be provided and we must receive your consent before we can assist you in conducting an online person search, completing the eligibility application, comparing and selecting qualified health plans (QHPs), enrolling in coverage through the Marketplace (HealthCare.gov), and providing ongoing account/enrollment maintenance.
When you apply to HealthCare.gov, the information that you provide will be submitted to CMS (Centers for Medicare and Medicaid Services) and will be maintained in a federal system of records.
Your confidential personal and financial information is used for Marketplace business purposes only and is only disclosed to individuals who are authorized to receive or view it.
We must keep a record of providing this notice and receiving consent from you to assist you in applying for and enrolling in coverage in the Marketplace.
Your signature is not required.
Please complete the form to the right.