I hereby grant authorization to Anna Garza, acting as the health insurance agent or broker, to represent me and my entire household, as applicable, for the purpose of enrolling in a Qualified Health Plan offered on the Federally Facilitated Marketplace. In accordance with this agreement, I permit the designated Agent to access and utilize the confidential information provided by me through written, electronic, or telephonic means, solely for one or more of the following purposes:
I acknowledge that the Agent will strictly adhere to the use of my personally identifiable information (PII) solely for the aforementioned purposes. The Agent is obligated to maintain the privacy and security of my PII during the collection, storage, and utilization for the stated purposes.
I understand that I am not obliged to disclose additional personal information beyond the requirements of the eligibility and enrollment application. I am aware that my consent remains effective until revoked, and I reserve the right to revoke or modify my consent at any time. Such revocation or modification can be facilitated by contacting my Agent or by utilizing the HealthSherpa dashboard.
