[Names]   is required to act in my best interest. [Names]   will follow privacy and information security standards when creating, collecting, disclosing, accessing, maintaining, storing, and/or using my PII and/or the PII of my authorized representative. Information about these standards will be provided. [Names]   aren’t expected or required to maintain or store any of my PII and/or the PII of my authorized representative, other than this authorization form, but if [Names] do maintain or store my PII, they will follow privacy and information security standards. I and/or my authorized representative do not need to provide  [Names] contact information, unless I want [Names] to follow-up with me on applying for or enrolling into coverage. My consent to follow- up is given by providing my phone number and/or e-mail address below. [Names]   I and/or my authorized representative don’t have to give  [Names] more information than I and/or my authorized representative choose to provide. The assistance [Names]  provide is based only on the information I and/or my authorized representative provide, and if the information provided is inaccurate or incomplete, [Names] may not be able to provide all the assistance available for my situation. If [Names]  are unable to assist me and/or my authorized representative, they will refer me or my authorized representative to another person who can help me (a Navigator or other Marketplace-authorized assistance personnel), or to the Exchange call center. [Names]   won’t charge me and/or my authorized representative a fee for any assistance provided. Please sign and date the form: Signature of Consumer/Consumer’s Legal or Marketplace Authorized Representative (please circle a status to indicate whether you’re the consumer or the consumer’s representative) Date Number and E-Mail Address for Follow-Up (Optional) Consumers may sign this authorization form themselves, or choose to have a legal or PLEASE NOTE: Marketplace Authorized Representative complete this form.
  [Names] is required to act in my best interest.   [Names] will follow privacy and information security standards when creating, collecting, disclosing, accessing, maintaining, storing, and/or using my PII and/or the PII of my authorized representative. Information about these standards will be provided.   [Names] aren’t expected or required to maintain or store any of my PII and/or the PII of my authorized representative, other than this authorization form, but if [Names] do maintain or store my PII, they will follow privacy and information security standards.  I and/or my authorized representative do not need to provide [Names] contact information, unless I want [Names] to follow-up with me on applying for or enrolling into coverage. My consent to follow- up is given by providing my phone number and/or e-mail address below.   [Names]  I and/or my authorized representative don’t have to give [Names] more information than I and/or my authorized representative choose to provide.  The assistance [Names] provide is based only on the information I and/or my authorized representative provide, and if the information provided is inaccurate or incomplete, [Names] may not be able to provide all the assistance available for my situation.  If [Names] are unable to assist me and/or my authorized representative, they will refer me or my authorized representative to another person who can help me (a Navigator or other Marketplace-authorized assistance personnel), or to the Exchange call center.   [Names] won’t charge me and/or my authorized representative a fee for any assistance provided. Please sign and date the form: Signature of Consumer/Consumer’s Legal or Marketplace Authorized Representative (please circle a status to indicate whether you’re the consumer or the consumer’s representative) Date Number and E-Mail Address for Follow-Up (Optional) PLEASE NOTE: Consumers may sign this authorization form themselves, or choose to have a legal or Marketplace Authorized Representative complete this form.
cac-authorization%20(4).docx