Applicant Authorization For Enrollment Assistance
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1
2AUTHORIZATION FOR ENROLLMENT ASSISTANCE
Certified Enrollment Entity Name
Entity Address
Entity Phone Number
Entity Email
Certified Enrollment Counselor Name and Certification Number
I,
__________, give my permission, or
___________,
my Authorized Representative (person acting for me), gives his/her permission, to the Covered California
Certified Enrollment Entity and Enrollment Counselor (together called “Counselor”) named above to give me
and/or my Authorized Representative information about my health coverage choices. This is to help me apply
for and enroll in health coverage through a Covered California Health Insurance Plan or Medi-Cal.
I give permission for the Counselor to see or use some of my Personally Identifiable Information and to help me
enroll in health coverage. My Personally Identifiable Information may include my name, home address, email
address, phone number, date of birth, social security number, financial information, and employment
information.
In this form, the words “me” or “my” include my Authorized Representative if I have one.
I understand that:
1. The Counselor will tell me about all coverage choices I may qualify for, including Covered California Health
Plans, Medi-Cal and AIM for Pregnant Women.
2. The Counselor cannot choose or recommend a health plan for me.
3. The Counselor will make sure my Personally Identifiable Information is private and secure. This is required
by law.
4. The Counselor may create, collect, give out, access, keep, store, and/or use my Personally Identifiable
Information and/or my Authorized Representative’s Personally Identifiable Information only to perform the
Certified Enrollment Counselor duties. This may include giving my Personally Identifiable Information to
Covered California, Covered California Health Plans, and the California Department of Health Care
Services, which runs Medi-Cal. The Counselor may not use my Personally Identifiable Information for any
other purposes.
5. Certified Enrollment Counselor duties also include:
Giving information and services in a fair, correct, and impartial way.
Giving information verbally and/or in writing about all coverage options for which I may qualify in my
language and in a way I can understand.
Giving information and help in a way that persons with disabilities can access and use.
Helping me choose a Covered California Health Plan or Medi-Cal or AIM for Pregnant Women. If I
consent, helping me apply for, enroll into, or renew coverage.
Referring me to agencies for help with a grievance, complaint, or question about my health plan,
coverage, or a decision made by or about my plan or coverage.
6. The Counselor must also offer public education activities. The Counselor will not use my Personally
Identifiable Information for this purpose.
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