Appendix E - Model Certified Application Counselor (Cac) Authorization Form (Page 2 of 2) in pdf

Ø ______________________________________________________________________ [Names]

is required to act in my best interest.

Ø ______________________________________________________________________ [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.

Ø

_____________________________________________________________________ [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.

Ø 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.

Ø ______________________________________________________________________ [Names]

Ø I and/or my authorized representative don’t have to give ________________________________

____________________________________________________________ [Names] more

information than I and/or my authorized representative choose to provide.

Ø 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.

Ø 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.

Ø _____________________________________________________________________ [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 ________________________

__________________________________________________________________

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.

Appendix E - Model Certified Application Counselor (Cac) Authorization Form Page 2