Appendix E - Model Certified Application Counselor (Cac) Authorization Form printable pdf download

APPENDIX E

Model Certified Application Counselor (CAC) Authorization Form

In Federally-Facilitated or State Partnership Marketplaces

CAC Designated Organization Name and Address:

_________________________________________________________________________________

CAC Designated Organization Phone Number and Email:

_________________________________________________________________________________

Individual CAC Name and Certification Number:

_________________________________________________________________________________

I, ______________________________, give my permission, or _________________________________

[Insert name of authorized representative], my legal or Marketplace authorized representative acting on

my behalf (“authorized representative”), gives permission to ____________________________________

_____________________________________________________________________________[Names]

to create, collect, disclose, access, maintain, use, and/or store my personally identifiable information (PII)

and/or the PII of my authorized representative, to perform the following duties of a CAC Designated

Organization or CAC

Ø

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;

Ø Help me complete my application for health coverage in a Qualified Health Plan (QHP) through

the Marketplace and for insurance affordability programs;

Ø 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 ______________________

_____________________________________________ [Names] if I choose to revoke my authorization.

I understand that _______________________________________________________________________

_______________ [Names] have the following responsibilities and will perform the following functions:

Ø ______________________________________________________________________ [Names]

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.

Ø ______________________________________________________________________ [Names]

will inform me of any possible conflicts of interest they might have.

Ø ______________________________________________________________________ [Names]

can’t choose a health insurance plan for me

NOTE TO CAC DESIGNATED ORGANIZATION AND INDIVIDUAL CAC: Each time [Names] appears in

this Authorization Form, the Name of the CAC Designated Organization and the name of the individual

staff/volunteer CAC should be inserted on the blank line in front of [Names].

These duties are set forth in 45 CFR §155.225.

Appendix E - Model Certified Application Counselor (Cac) Authorization Form