ACA Consent FormConsent FormBy submitting this form, you acknowledge and agree: 1. The provided information is accurate and true to the best of my knowledge. 2. Illinois Health Agents Inc. will be your agent of record and access your healthcare.gov account to change your agent of record, inquire about plans, respond, and make updates. 3. Illinois Health Agents Inc. NPN 14924332 and its Representatives have authority, as the agent of record, to complete tasks and inform you about your account. 4. Your agent may periodically review your account for required documentation. If another agent alters your plan, your agent can assume control and inform you. 5. You can revoke these authorizations in writing via email help@ihealthagents.com or text message, or verbally during a phone call to (312) 726-6565 I consent to SMS/MMS messaging, calls, and emails for fulfillment of my request for health insurance, customer care, and submitting further requests.I Acknowledge and Agree to all the above and have read the Privacy Policy.(Required) I agreeName(Required) First Last Phone(Required)Email(Required) Enter Email Confirm Email Please read the paragraph below before signing the formI understand that the business and agent above will not use or share my personally identifiable information (PII) for any purposes other than for those which I have agreed. Illinois Health Agents Inc. and its Representatives 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 contacting Illinois Health Agents Inc. and its Representatives at any time by email help@ihealthagents.com or phone (312) 726-6565. By signing below, you affirm that you have read, understand, and acknowledge the information included in your application and that you give the agent permission to begin working on your behalf in the marketplace. This permission includes the ability to: 1) Access my account, gather information, and update and act as the agent of record. 2) Complete any existing or new application for eligibility for or enrollment into a health plan. 3) Provide ongoing account maintenance or assistance as needed. I have reviewed my application. I Acknowledge and Agree to all with the above statements and the information I have provided is accurate and complete.(Required) I agreePhoneThis field is for validation purposes and should be left unchanged.Δ
