Health insurance authorization | Noble Insurance Brokers LLC

Complete this quick 2-minute authorization to allow us to act as your agent in securing the right health coverage for you and your family.
You may revoke this authorization at any time. Once submitted, we’ll reach out within 24 hours to finalize any remaining details.

Client Information & Consent Form

First name

Middle name

Last name

DOB

Phone number

Email address

Authorization details

I (your name wil show here) give my permission to Maria Valecillos Gutierrez to serve as the health insurance Agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated marketplace as well as the New Jersey marketplace. By consenting to this agreement, I authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by phone only for one or more of the following

Searching for an existing Marketplace application

Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premium

Providing ongoing account maintenance and enrollment assistance, as necessary Responding to inquiries from the Marketplace regarding my application

I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above*

I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge.*

I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by contacting my Agent.*

Primary writing agent contact information

Name: Maria Valecillos Gutierrez

NPN: 19032336

Phone number: (346) 818-3331

Email: info@nobleinsurancebrokersllc.com

Agency name: Noble Insurance Brokers LLC

Agency NPN: 21114532

Privacy & Use of Information

Protecting your personal information is important to Noble Insurance Brokers LLC and we will keep your information private as required by law. Your answers on this application will only be used to determine eligibility for health coverage. The federally facilitated marketplace or the individual state exchanges will check your answers using the information in their electronic database and the databases of other state and federal agencies. If the information doesn't match, they may ask you to send them proof.

We won't ask any questions about your medical history. Household members who don't want coverage won't be asked questions about citizenship or immigration status.

Important:

As part of the application process for health insurance, the federally facilitated marketplace or the individual state exchanges may disclose and retrieve your information through secure electronic data exchanges with the Internal Revenue Service (IRS), Social Security Administration (SSA), the Department of Homeland Security (DHS), or a consumer reporting agency (such as Equifax). These data exchanges are authorized by the Affordable Care Act. They need this information to verify your identity, income and other information on your application to determine if you are eligible for health coverage and financial help through the federally facilitated marketplace or the individual state exchanges. They may also check your information at a later time to make sure your program eligibility is up to date.

The federally facilitated marketplace or the individual state exchanges may also communicate with you, or Noble Insurance Brokers LLC, and they provide the information to the health insurance company you select so that it can enroll you in your health plan. Additionally Noble Insurance Brokers LLC will be able to see your application information.

Information in this application may also be shared with the individual state Medicaid agencies and Children’s Health Insurance Programs. The individual state Medicaid agencies will keep your information private as required by law. Your answers on this application and any additional information you provide to the federally facilitated marketplace or the individual state exchanges will be used for determination of eligibility for its programs, to verify identity and financial information such as income and bank account information, to determine the amount of medical assistance or coverage, to provide benefits, to pay for benefits, and to prevent duplicate or incorrectly paid benefits, and for recovery purposes.

Learn more about the federally facilitated marketplace privacy practice

Learn more about the State of New Jersey’s Privacy Policy

Learn more about Noble Insurance Brokers LLC privacy practice

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Consent Required

I consent to have my information sent, retrieved and used as outlined above for all the individuals that will be included in my application. I have reviewed the individual Privacy Policies listed above and understand that these policies apply to each individual entities and their correspondent affiliates.

By checking this box, I confirm that I am signing this form electronically. I understand that my electronic signature is legally binding and has the same legal effect as a handwritten signature. I authorize the release and use of my information as described in this form.

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