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CONSENT FOR BROKER ASSISTANCE

AS REQUIRED UNDER THE 2023 CMS-9899-F AMENDMENT OF 45 CFR § 155.220

This consent form outlines your rights. Please read it carefully.

As a licensed Health Insurance Broker, Robert Routt of Routt Insurance has completed the annual Affordable Care Act certification by the Marketplace in your state. With this yearly training, and an individual or family's formal consent, brokers are authorized to search for and assist households with their Marketplace account. The purpose of this form is to receive your informed written consent.

Terms of Consent

I give my permission to Routt Insurance, and/or their staff to provide the following services on behalf of myself, and my entire household if applicable.

  1. Search for an existing Marketplace application;

  2. Completing an application for eligibility and enrollment in a marketplace Qualified Health Plan or government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace Premiums or enrollment in off-exchange insurance products as applicable.

  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 Routt Insurance  and/or their staff will not share my personally identifiable information (PII)

 and they will ensure that my PII is kept private and safe when collecting, storing, and using my information 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 my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time. I understand that requests must be made in writing, either by sending the request via certified mail to the address below or via email to rob@routtinsurance.com

Agency Contact Information

Routt Insurance | (727) 513-8338 | 3455 Countryside Blvd Unit 29 Clearwater, FL 33761

Agent Point of Contact

My Broker | Robert Routt | rob@routtinsurance.com | NPN: 546852

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