Marketplace Consent & Attestation

Per government regulations we must have written consent to assist you with your Marketplace enrollment. Thank you for your cooperation.
1.I give my permission to Westhouse Insurance Agency, LLC (“Agency”), National Producer Number 18352501 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.(Required.)
2.I authorize Westhouse Agency and its Agents to view and use the confidential information provided by me in writing, electronically, or by phone only for one or more of the following:
 - Searching for an existing Marketplace application
 - Completing an application for eligibility and enrollment in a Marketplace
Qualified Health Plan or other government insurance affordability
programs, such as Medicaid or advance tax credits to help pay for
Marketplace premiums
 - Providing ongoing account maintenance and enrollment assistance, as
necessary
 - Responding to inquiries from the Marketplace regarding my application(Required.)
3.I understand that the Agency or its representatives will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.(Required.)
4.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.(Required.)
5.I understand that I do not have to share additional personal information about myself or my health with the Agency beyond what is required on the application for eligibility and enrollment purposes.(Required.)
6.I understand I must verify that any provider participates with my health insurance network before obtaining services. If my provider is not in network, I may have to pay a higher percentage of the cost, or all the costs incurred for care. Network participation can be obtained via the carrier website or by contacting the health insurance carrier directly using the customer care number on the back of my insurance card.(Required.)
7.If my first premium payment is not made on or before the requested effective date, I understand that my policy will not activate, and I will not be eligible to enroll until the following calendar year. Some carriers will extend the initial premium due date by 30 days, but it is my responsibility to coordinate this with the carrier upon receiving the first invoice.
Autopayment can be set up by contacting the carrier directly. Contact information will be provided with my first invoice 10 business days after Marketplace has approved my eligibility for coverage.
8.No one applying for health coverage on this application is incarcerated.
9.I must cancel my Marketplace plan when I become eligible for Medicare or Medicaid. The Marketplace plan will not pay claims or reimburse premiums paid if I am found eligible for Tricare, Medicare or Medicaid.
10.I understand that when I file my federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my Marketplace application. I understand that if the income on my tax return is lower than the amount of income on my application, I may be eligible to get an additional premium tax credit amount. On the other hand, if the income on my tax return is higher than the amount of income on my
application, I may owe additional federal income tax.
11.I agree to allow the Marketplace to use income data, including information from tax returns, for the next 5 years (the maximum number of years allowed). The Marketplace will send me a notice, let me make any changes, and I can
opt out at any time.
12.I understand the premium tax credit or cost share reduction will be paid on my behalf by the federal government to reduce the cost of health coverage for myself and/or my dependents.
13.I must file a federal income tax return by April 15. If I'm married at the end of the year, I must file a joint income tax return with my spouse. No one else will be able to claim me as a dependent on their federal income tax return. I
will claim a personal exemption deduction on my federal income tax return for any individual listed on this application as a dependent who is enrolled in coverage through this Marketplace and whose premium for coverage is paid in whole or in part by advance payments.
14.I must tell the Marketplace if information I listed on my application changes, such as but not limited to name, address, familial status, dependents, household income (if eligible for a subsidy) and eligibility for coverage through an employer. I understand that a change in my information could affect my eligibility for members of my household. I understand that a change in my information may impact my premium tax credit and cost sharing reduction.
15.I understand that I’m NOT eligible for a premium tax credit if I’m found eligible for
 Employer sponsored coverage
 Medicaid
 Medicare
 Health or Retirement Reimbursement Account or
 Tricare
16.I agree to have my information, and I have consent for information on the named persons in my application, to be used, retrieved and verified with the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security (DHS), and/or a consumer reporting agency. This information is needed to check eligibility for coverage and financial help.
The information may also be checked later to make sure the information is up to date. I will be notified by the Health Insurance Marketplace if something has changed. I understand that my information is kept private as required by law.
17.Full Legal Name(Required.)
18.Phone Number(Required.)
19.Email Address(Required.)
20.Today's Date(Required.)