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  • Health
    • Health Insurance
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  • Medicare
    • Medicare A B C D
    • Medicare Advantage
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  • Life
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Privacy and the use of your Information

CMS Model Consent Form for Marketplace Agents and Brokers

I,  [insert name of primary household contact on form below], give my permission to

Christopher Ruhm, National Producer Number 3772700 to serve as the health insurance agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned Agent to view and use the confidential information 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 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; or Responding to inquiries from the Marketplace regarding my Marketplace application.
  • I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.
  • I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. 
  • I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. 
  • I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by the means I provide when you submit the form (email or phone).

Consent Form

Consent

Consent Form

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Consent Agreement

By completing the consent form,  you (the consumer) grant Christopher Ruhm/NPN 3772700 permission to access and assist with your Marketplace application based on the collection of data listed above. Upon hitting submit that is your electronic signature and you will receive a return message with options to opt out at anytime via phone or email. I will maintain this receirpt on file for 10 years per CMS rules.

Ruhm Insurance Agency, LLC

(513) 496-3877 or info@chrisruhm.com

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

  

Neither the insurance company nor the agent/broker making a solicitation have any connection or affiliation with, and are not in any way sponsored by, the federal or state government, the Social Security Administration, the Centers for Medicare and Medicaid Services, or the Department of Health and Human Services. 

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