Patient Protection and Affordable Care Act
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law. This model consent form will not supersede any State Agent of Record, Broker of Record, or other form required by a QHP issuer for purposes of making commission payments to the proper agent or broker for assisting a particular consumer.
Registered agents and brokers assisting consumers apply for and enroll in Marketplace coverage must document consumer consent prior to accessing or updating their Marketplace information. CMS does not prescribe the manner in which agents and brokers must document consent. Instead, there are different formats that may be acceptable for agents and brokers to use to document consumer consent, such as via a recorded phone call, text message, email, electronic document with digital signatures, physical document with wet signatures, etc. This model consent form serves as an example for how agents and brokers may document consent via a physical document with wet signatures.
Since this model consent form is a best practice for obtaining consumer consent, you may tailor the form to address the needs of your specific business model in addition to meeting the CMS requirement to document consent from a consumer prior to assisting the consumer enroll in coverage in the Marketplace, including prior to conducting a person search. For example, if an Agency is involved, you may clarify specifically who else within the Agency other than the writing Agent is able to view and use the consumer’s PII to assist the writing Agent in enrolling the consumer in Marketplace coverage for compliance, commissions, or other relevant purposes as you see fit.
submissions or payments made via this website do not constitute a
binding agreement to your policy or coverages. Changes and
payments to policies are not effective or binding until you, or any
party involved, receive official notice from either your insurance agent,
or your insurance company. If you have any questions, please feel free to
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we will not resell your information to any third-party.