ACA Consent Form

You give your assisting agent Mark Meadows and all employees of Acquire Healthcare permission to act as your health insurance agency, agent, or broker for you and your household. By agreeing to these terms you are requesting that we become the agent of record on your application.

By consenting to this agreement, you authorize the above-mentioned Agent and Agency employees to view and use the confidential information provided by you either in writing, electronically, or by telephone for the purposes of 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 and CHIP 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 your Marketplace application.

Your Agent or authorized representative will ensure that your personally identifiable information (PII) is kept private and secure when collecting, storing, and using your PII for the stated purposes above. Your Agent or authorized representative will not use or share your PII for any purposes other than those recently stated.

You confirm that the information you have provided for your Marketplace eligibility and enrollment application is true to the best of your knowledge. You understand that you do not have to share additional personal information about yourself or your health with your Agent beyond what is required on the application for eligibility and enrollment purposes.

You understand that your consent remains in effect indefinitely until you revoke it, and you may revoke or modify your consent at any time by contacting Acquire Healthcare directly at 503-828-1970 or at info@acquirehealthcare.com

Unless you have notified us in writing that you have granted authorization for another agent of record to be listed on your application, we will assume that the change was made fraudulently without your consent. To maintain ongoing service you grant AcquireHealthcare and it’s authorized agents permission to update the application listing Christopher Wang or the authorized agent through AcquireHealthcare to be updated as the agent of record at any time.

You also confirm that you have reviewed the information on the eligibility application and attest that it is accurate, and you are requesting to have your application submitted.

Please sign below if you consent to this agreement.

 

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Signature Certificate
Document name: Mark Meadows - ACA Consent
lock iconUnique Document ID: d79cb177f956f3b69df02ec90c5eb88f150bb7fd
TimestampAudit
February 19, 2024 11:52 am PDTMark Meadows - ACA Consent Uploaded by Billy Test - mmeadows@acquirehealthcare.com IP 50.209.61.189
February 19, 2024 11:54 am PDT Document owner docusign@acquirehealthcare.com has handed over this document to mmeadows@acquirehealthcare.com 2024-02-19 11:54:47 - 50.209.61.189