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I give permission to Jennifer Francis to create, collect, disclose, access, maintain, use, and/or store my personally identifiable information (PII) and/or the PII of my authorized representative, to perform the following duties:

Inform me and/or my authorized representative about the full range of health coverage options and insurance affordability programs for which I’m eligible;
Help me complete my application for health coverage in a Qualified Health Plan (QHP) through the Marketplace and for insurance affordability programs;
Help me enroll in a QHP or in an insurance affordability program.

I understand that I may revoke this authorization at any time and will notify Jennifer Francis if I choose to revoke my authorization.I understand that Jennifer Francis has the following responsibilities and will perform the following functions:

Inform me and/or my authorized representative about the full range of Marketplace health coverage options and insurance affordability programs for which I’m eligible, help me apply for health coverage, and help me enroll.
Inform me of any possible conflicts of interest.
Not choose a health insurance plan for me.
Act in my best interest.
Follow privacy and information security standards when handling my PII and/or the PII of my authorized representative.
Not expected or required to maintain or store my PII beyond this authorization form; if PII is stored, it will follow privacy and information security standards.
I do not need to provide contact information unless I want follow-up assistance. Consent to follow-up is given by providing phone number(s) and/or email address.
I do not have to provide more information than I choose to.
The assistance provided is based only on the information I or my authorized representative provide. Inaccurate or incomplete information may affect assistance.
If Jennifer Francis cannot assist, she will refer me to another person or the appropriate call center.
No fee will be charged for any assistance provided.

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