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I am authorizing a licensed Health Insurance Agent to review, to submit into a free plan or to refer my Health Insurance enrollment to a qualified entity whenever deemed necessary. I as a customer allow access to my Healthcare.gov or Medicaid accounts to make any updates/uploads as necessary and also to review and advise year to year, using any and all reasonable efforts to ensure that I the customer have a sound decision in my Healthcare plan for the year. I as the customer agree that I qualified for one of the many SEP’s during the year of 2022. (Ex: qualified for unemployment, Covid 19, Etc) I as a customer acknowledge receipt of HIPPA Privacy Information at the time of enrollment. By filling out and providing my personal information and signing, I certify that all of the above information is correct to the best of my knowledge and I give authorization to be enrolled into a free health insurance plan.
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