Consent Form

CMS Model Consent Form for Marketplace Agents and Brokers

I, ____________________ [insert name of primary household contact], give my permission to

Christopher Walker and Spinella Insurance Agency 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. 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:

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 and CHIP or advance tax credits to help pay for Marketplace premiums; Providing

ongoing account maintenance and enrollment assistance, as necessary; or 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 email to c.walker.ins@protonmail.com.

Name of Primary Writing Agent: Christopher E Walker

Agent National Producer Number: 19558861

Phone Number: 434.841.1913

Email Address: c.walker.ins@protonmail.com

Name of Agency (if applicable): Spinella Insurance Agency

Agency National Producer Number: 21355599

Owner of Agency: Christopher E Walker and Melanie S Walker

Phone Number: 434.841.1913 and/or 434.661.8274

Email Address: c.walker.ins@protonmail.com

Name of Primary Household Contact

and/or Authorized Representative:________________________________________________

Phone Number:_____________________________________________________________

Email Address:______________________________________________________________

Signature:_________________________________________________________________

Date:_____________________________________________________________________

PRA DISCLOSURE: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a

collection of information unless it displays a valid OMB control number. The valid OMB control number for this

information collection is 0938-1438, expiration date is XX/XX/20XX. The time required to complete this information

collection is estimated to take up to 0.10 hours per applicant per year, including the time to review instructions,

gather the information needed, and complete and review the information collection. If you have comments

concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500

Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents

containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not

pertaining to the information collection burden approved under the associated OMB control number listed on this

form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your

documents, please contact Brian Gubin at Brian.Gubin@cms.hhs.gov.