AUTHORIZATION FORM FOR CERTIFIED APPLICATION COUNSELOR DESIGNATED ORGANIZATIONS AND CERTIFIED APPLICATION COUNSELORS (CACS) IN STATES WITH A FEDERALLY FACILITATED MARKETPLACE (FFM)

Families First Health and Support Center | 8 Greenleaf Woods Drive | Portsmouth, NH 03801

603-422-8208 | Info@familiesfirstseacoast.org

Individual CAC Name:  Susan Turner            Certification Number:  NHCDOA1200002

PLEASE NOTE: Consumers may complete and sign this authorization form themselves, or choose to have a legal or Marketplace Authorized Representative complete and sign it for them.

I,                                                          , give my permission, or                                                  , my legal or Marketplace authorized representative acting on my behalf (“authorized representative”), gives permission to Families First Health and Support Center and Susan Turner to create, collect, disclose, access, maintain, use, and/or store my personally identifiable information (PII) and/or the PH of my authorized representative, to perform the following duties of a CAC Designated Organization or CAC [1]:

• Inform me and/or my authorized representative about the full range of Marketplace health coverage options and insurance affordability programs for which I’m eligible;
• Help me complete my application for health coverage in a Qualified Health Plan (QHP) through the Marketplace and for insurance affordability programs;
• Help me enroll in a QHP or in an insurance affordability program.

I understand that I may revoke this authorization at any time and will notify Families First Health and Support Center and Susan Turner if I choose to revoke my authorization.

I understand that Families First Health and Support Center and Susan Turner has the following responsibilities and will perform the following functions:

• Families First Heath and Support Center and Susan Turner will inform me and/or my authorized representative about the full range of Marketplace health coverage options and insurance affordability programs for which I’m eligible, will help me apply for health coverage in a QHP through the Marketplace and for insurance affordability programs, and will help me enroll in a QHP or in an insurance affordability program.
• Families First Health and Support Center and Susan Turner will inform me of any possible conflicts of interest they might have.
• Families First Health and Support Center and Susan Turner can’t choose a health insurance plan for me.
• Families First Health and Support Center and Susan Turner is required to act in my best interest.
• Families First Health and Support Center and Susan Turner will follow privacy and information security standards when creating, collecting, disclosing, accessing, maintaining, storing, and/or using my PH and/or the PII of my authorized representative. Information about these standards will be provided.
• Families First Health and Support Center and Susan Turner 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 Families First Health and Support Center and Susan Turner do maintain or store my PII, they will follow privacy and information security standards.
• I and/or my authorized representative don’t need to provide Families First Health and Supports Center and Susan Turner contact information unless I want Families First Health and Support Center and Susan Turner 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 email address below.
• I and/or my authorized representative don’t have to give Families First Health and Support Center and Susan Turner more information than I and/or my authorized representative choose to provide.
• The assistance Families First Health and Support Center and Susan Turner provide is based only on the information I and/or my authorized representative provide, and if the information provided is inaccurate or incomplete, Families First Health and Support Center and Susan Turner may not be able to provide all the assistance available for my situation.
• If Families First Health and Support Center and Susan Turner 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.
• Families First Health and Support Center and Susan Turner 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:                                        

Phone 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.

[1] These duties are set forth in 45 CFR §155.225.