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Home
Medicare Coverage
What We Do
What We Offer
Medicare Made Simple
Who We Represent - Medicare
Request a Medicare Appointment
ACA Coverage
Who We Represent - ACA
Request an ACA Appointment
About
Who We Are
Contact
Testimonials
Scope of Appointment
Request an ACA Appointment
ACA Coverage
Who We Represent - ACA
Request an ACA Appointment
Requesting an ACA Appointment
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Coveside Senior Solutions LLC (dba Coveside: Healthcare Coverage Options) CoverME.gov Client Consent & Information Use Authorization
1. Purpose of Broker Relationship: By signing this consent form, I give my permission to Miranda Curtis and Coveside: Healthcare Coverage Options and its licensed agents, 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 (coverme.gov). I understand that by consenting to this agreement, I authorize the above-mentioned broker to assist me with the following: - Searching for an existing Marketplace application; - Assisting in 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 premiums; - Providing ongoing account maintenance and enrollment assistance, helping me report changes, as necessary; or responding to inquiries from the Marketplace regarding my Marketplace application. - Understanding my health coverage options on CoverME.gov, by explaining eligibility, plan selection, and renewal procedures.
2. Information to Be Used: The broker may collect and use the following personally identifiable information (PII) as required for my application and enrollment: - Full legal name, address, date of birth, and Social Security Number. - Income and tax household information. - Immigration or citizenship status. - Medical needs or preferences (only as necessary to identify suitable coverage). - Other documentation required for eligibility or coverage. 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 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.
3. Privacy Statement: My information will be used only for the purposes of obtaining and managing health coverage through CoverME.gov and will not be shared for other purposes without my consent. Coveside: Healthcare Coverage Options and its employees agree to maintain the privacy and security of my data under federal and state law.
4. Duration of Consent: I understand that my consent remains in effect until I revoke it and I can revoke this consent at anytime by notifying Miranda Curtis in writing.
5. Signature: By signing below, I confirm that I understand and agree to the terms outlined above and voluntarily grant the broker permission to assist me with the CoverME.gov process. 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.
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Name of Primary Writing Agent: Miranda Curtis (Coveside Senior Solutions LLC dba Coveside: Healthcare Coverage Options) Agent National Producer Number: 18842901 Phone Number: (207) 553-2535 Ext. 103 Email Address: miranda@covesidellc.com
Thank you!
