Client Consent & Insurance Questionnaire

I, [Consumer Full Name], give permission to Michael Galvan Insurance to serve as my health insurance agent or broker and, when applicable, to assist members of my household for purposes related to enrollment in a Qualified Health Plan offered through the Federally Facilitated Health Insurance Marketplace.

By providing this consent, I authorize Michael Galvan Insurance to assist me with the following activities:

• Searching for and accessing an existing Marketplace application associated with me or members of my household when necessary to provide enrollment assistance.
• Assisting with an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other insurance affordability programs, including Medicaid, CHIP, and advance premium tax credits that may help reduce the cost of Marketplace coverage.
• Helping me review available health insurance options and assisting me with enrolling in the health plan that I select.
• Providing ongoing Marketplace account and enrollment assistance, when requested or necessary.
• Responding to my questions concerning my Marketplace application, eligibility, enrollment, or coverage.

I understand that information I provide will be used only as reasonably necessary to assist me with health insurance eligibility, enrollment, and related Marketplace services.

Michael Galvan Insurance will take reasonable steps to protect the confidentiality and privacy of the information I provide and will not use or disclose my personal information for purposes unrelated to the health insurance services described in this authorization, except as permitted or required by law.

For my protection, this website consent form does not request and I should not enter Social Security numbers, government identification numbers, immigration document numbers, Marketplace usernames or passwords, banking information, credit or debit card information, or other highly sensitive account credentials.

I understand that additional information may be required later to complete an official Marketplace application or health insurance enrollment. If additional information is required, it will be requested separately through an appropriate enrollment or secure process.

I agree to provide information that is true and accurate to the best of my knowledge.

I understand that I will have an opportunity to review and confirm the accuracy of the information entered into my Marketplace eligibility and enrollment application before the application is submitted.

I understand that I am responsible for notifying my agent or the Health Insurance Marketplace if information affecting my eligibility or coverage changes.

This authorization will remain effective for one year from the date I provide my consent, unless I revoke it earlier.

I understand that I may revoke or modify this authorization at any time by contacting Michael Galvan Insurance by telephone, email, or written request.

Revoking this authorization will not affect actions already taken with my permission before the revocation was received.

Primary Writing Agent: Michael Galvan

Agency: Michael Galvan Insurance

Phone: 210-862-8155

Email: mike@mg-insurance.com