Applicant Authorization For Enrollment Assistance Page 2
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2AUTHORIZATION FOR ENROLLMENT ASSISTANCE
7. The Counselor must know the rules for Covered California Health Plans, Medi-Cal and AIM for Pregnant
Women.
8. If the information I give is wrong or incomplete, the Counselor may not be able to help me make the best
decisions. The Counselor’s help is based only on information I or my Authorized Representative give.
9. If the Counselor can’t help me, he or she will refer me to another Counselor, or to the Covered California
Service Center, who can help me.
10. The Counselor will not charge me a fee. The help is free.
11. I must sign this form for the Counselor to give help. If I do not sign this form, I can still apply for and enroll
in health coverage through Covered California or Medi-Cal or AIM for Pregnant Women. The Counselor
will not be able to help me.
12. This authorization will expire when I communicate to the Counselor that I wish to cancel my
authorization. I may cancel or limit my authorization in writing at any time. I will notify the Counselor if I
choose to cancel my authorization.
13. The Counselor or Covered California must keep this form for six years.
Covered California needs your name and signature on this form to identify you. If you do not give your name
and signature on this form, a Counselor will not be able to help you. These federal regulations give Covered
California the right to collect and keep the information on this form: 45 C.F.R. § 155.210, 45 C.F.R. § 155.215.
Covered California must give you this Privacy Statement under CA Civil Code § 1798.17. Covered
California's Notice of Privacy Practices is available at If you have questions about
your records, you can call or write to the Privacy Officer at (800) 889-3871 or P.O. Box 1347 Sacramento,
CA 95814.
Sign and date on the lines:
Signature ________________________________________________
Date______________
For Certified Enrollment Counselor:
I affirm under penalty of perjury that:
I am a Certified Enrollment Counselor affiliated with a Certified Enrollment Entity as defined in California
Code of Regulations Title 10, Chapter 12, Article 8, section 6650.
I gave all information in this authorization form to the applicant in a language and way he or she
understands.
I ensured all information on this form was accessible to those with disabilities by providing disability-
related modifications or accommodations when necessary, including auxiliary aids, Braille, large print or
other tools and services.
I explained to the consumer what information is Personally Identifiable Information and that this will only
be used to determine eligibility for health coverage.
I obtained oral authorization from the consumer consenting to the release of his or her Personally
Identifiable Information to me in order to fulfill my duties as described in California Code of Regulations
Title 10, Chapter 12, Article 8, section 6664.
Signature __________________________________________________
Date______________
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