Consent & Acknowledgment

Please review and complete the form below to proceed.

CMS Model Consent Form for Marketplace Agents and Brokers

I give my permission to Peterson Insurance Solutions to serve as the health insurance agency for myself and my entire household, if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally-Facilitated Marketplace or State-Based Marketplace on the Federal Platform.

By providing my consent, I authorize Jennifer Peterson (agent) and Peterson Insurance Solutions (agency) to view and use my confidential information, including personally identifiable information (PII), provided by me in writing, electronically, or by telephone only 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 an application for government affordability programs such as Medicaid and CHIP or advance payments of the premium tax credit;
Providing ongoing account maintenance and enrollment assistance; or
Responding to inquiries from the Marketplace regarding my application.

I understand that the agent and agency will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The agent and agency will ensure that my PII is protected when creating, collecting, accessing, maintaining, storing, and using my information for the stated purposes above.

I understand that I am not required to provide additional personally identifiable information (PII) or protected health information (PHI) beyond what is necessary to complete my Marketplace application.

This consent remains in effect until I revoke it. I may revoke or modify my consent at any time by submitting my request in writing to the agency listed below.

Agency Information

Agency Name: Peterson Insurance Solutions

Agency Address: 6650 Rivers Ave., Suite 100

Charleston, SC, 29406

Agency Phone: 803-346-5848

Agency Email: [email protected]

Agency Owner: Jennifer Peterson

Agency License No: 3003764421

Agency NPN: 21674028

Agent Information

Agent Name: Jennifer Peterson (Agent of Record)

Agent Phone: 803-346-5848

Agent Email: [email protected]

Agent NPN: 20763803

Consumer Information

Name of Primary Household Contact / Authorized Representative:

Date of birth *

Phone *

Email *

Address

Street Address *

City *

State *

County *

Postal Code *

CMS Consent Statement

I give my consent to Peterson Insurance Solutions and Jennifer Peterson to serve as my authorized health insurance agent and agency for myself and my entire household, if applicable, for enrollment in a Qualified Health Plan through the Federally-Facilitated Marketplace or State-Based Marketplace on the Federal Platform. I authorize the agent/agency to access and use my personal information only for the purposes of: Searching for an existing Marketplace application Completing an application for eligibility and enrollment Providing ongoing account maintenance and enrollment assistance Responding to Marketplace inquiries related to my application

I understand that my personally identifiable information (PII) will not be used or shared for any other purpose and will be protected in accordance with applicable privacy and security standards.

I understand that I am not required to provide additional personally identifiable information (PII) or protected health information (PHI) beyond what is required for Marketplace enrollment.

I consent to Peterson Insurance Solutions and Jennifer Peterson acting as my Marketplace agent for enrollment and account assistance and authorize the use of my information solely for Marketplace purposes.

This consent remains valid until revoked in writing.

Signature (Sign Here)

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