Acknowledgment Form for the Federally Facilitated Marketplace, Penni & Get Covered NJ State Exchanges

I give my permission to Lynn Donato to serve as the health insurance agent or broker for myself and my entire household, if applicable, for enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace, Penni, and Get Covered NJ. 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 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 or State Exchange 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 or State Exchange regarding my application.

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 emailing or calling my agent.

Name of Primary Writing Agent: Lynn Donato

Phone Number: 973-898-5959

Email Address: Lynn@thefutureyears.com