Consent

I, ___________________ (Name), give my permission/consent from today, _______________, and hereafter, to Kika Elkind,  Odalis Lopez, Mary Saiz, Travis Trinh and all KLE Solutions, LLC staff (Jennifer Manchola) & partners to serve as the health insurance agent/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:

1. Searching for an existing Marketplace application;
2. 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;
3. Providing ongoing account maintenance and enrollment assistance, as necessary; or
4. 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 calling KLE Solutions at 772-212-0555 followed by an email to consent@kikains.com with "revoke consent" on the subject line and include my full name, current marketplace application number, my signature and date.

And will keep in mind that:

- The marketplace will auto-renew this plan for up to 5 years if I do not update my application.

- If I should become eligible for other qualifying coverage like Medicaid or work insurance, without making changes to my application, I might be responsible to pay back all the tax credits received and the marketplace could cancel my plan if they find that I’m enrolled in Medicaid.

- I will file my income taxes to reconcile the tax credits used to pay for the plan I selected, and if I earned more than the amount on the application, I will be responsible to pay the difference with my taxes.

- If I have any changes to the information provided for the application, I will contact Kika, Jennifer or the marketplace to update it.  

I confirm consent to receive text messages at the phone number provided. Messages consist of reminders (appointment, payment, documentation), and from time to time  about other products and services we offer.  Message & data rates may apply.  Message frequency varies. Reply to text "stop" to unsubscribe to receive text messages.