Per new government regulations we must have written consent to assist you with your Marketplace enrollment.  Thank you for your cooperation.

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* 1. I give my permission to Westhouse Insurance Agency, LLC (“Agency”), National Producer Number 18352501 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.

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* 2. I authorize Westhouse Agency and its Agents to view and use the confidential information provided by me in writing, electronically, or by phone only for 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 or advance tax credits to help pay for
       Marketplace premiums
 - Providing ongoing account maintenance and enrollment assistance, as
      necessary
 - Responding to inquiries from the Marketplace regarding my application

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* 3. I understand that the Agency or its representatives 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.

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* 4. 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.

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* 5. I understand that I do not have to share additional personal information about myself or my health with the Agency beyond what is required on the application for eligibility and enrollment purposes.

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* 6. I understand that my consent remains in effect until I revoke it and I may revoke or modify my consent at any time by contact Westhouse Insurance Agency at 616-970-2503 or at Admin@WesthouseAgency.com

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* 7. Full Legal Name

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* 8. Phone Number

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* 9. Email Address

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* 10. Todays Date

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