Georgia Access Agents Consent Form

The below form is used for Georgia-based residents looking to make our expert and licensed Agent, Karim, their office health cover agent. Karim offers direct genuine assistance, without involving those long call centers and frustrating long hold waits. Experience quality assistance by our Agent Karim.

Consumer Consent Form for Georgia Access Agents

Consumer Name

First Name

Last Name

Date

MM

DD

YYYY

Agent/Agency Name: Karim Mohamed

NPN: 20774572

I give permission to the above mentioned agent/agency to serve as the health insurance agent for myself and my entire household if applicable, for enrollment in a Qualified Health Plan offered on the Georgia State-based Exchange (Georgia Access). By consenting to this agreement, I authorize the above-mentioned agent/agency to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purpose of one or more of the following:

1) I give permission to access my information for the purpose of helping me complete an application for eligibility and enrollment in a Qualified Health Plan or other insurance affordability programs, such as Medicaid and PeachCare for Kids® (CHIP) or advance tax credits to help pay for insurance premiums.

2) I agree that I have been informed and agree with all the disclaimers included in my exchange application.

3) I understand the plan(s) I am being enrolled in and agree that I wish to be enrolled in that plan; I understand that I may cancel the delegation at any time either within the Georgia Access portal, a certified partner portal, or by calling the Georgia Access contact center at 1-888- 687-1503.

4) I give the agent permission to assist me in maintaining my information and changing my plans in the future without requiring consent. I understand that I am not obligated to provide this consent, but if I do not, I will need to document a new consent every time I require future assistance from my agent.

5) I give any member of their agency permission to assist me in maintaining my information and changing my plans in the future without requiring consent. I understand that I am not obligated to provide this consent, but if I do not, I will need to document a new consent every time I require future assistance from my agent.