Personally Identifiable Information (P.I.I.) Consumer Consent Form

Broker Name: Larrence Reid  |  Broker NPN: 17665915

Agency Address: 1418 E. Busch Blvd. Suite 101, Tampa, FL 33612

Your licensed agent/broker has permission to:

• Conduct a consent for consumer application using approved CMS/HCGov website for the Marketplace
• Assist with completing or eligibility applications
• Assist with plan selection and enrollment
• Assist with ongoing account maintenance

• Comprised of P.I.I. includes but not limited to: Name, Date of Birth, Phone Numbers, Age, Medical information, Local/County Records, Tax information, Social Security Numbers, and/or Address Information
• Agent will only ask for the minimum amount of P.I.I. necessary for them to carry out their functions and responsibilities
• Consumer can revoke consent with agent present at any time
• All P.I.I. will continue to be protected as private even after the revocation of a consumer by a consumer or in the event of agent's relationship with CMS being terminated

The agent has permission to speak to the consumer about life/ancillary products that can help to explain a consumer's Out-of-Pocket expenses regarding their marketplace plan. These products are not related to the marketplace and enrollments can be completed at any time throughout the year.

By law, CMS requires agents to obtain certain forms of personally identifiable information for the purpose of comparing information provided on the application to the applicant's income, residency status, and citizenship status among other things to assist in determining the applicant's eligibility for subsidies (assistance in paying monthly premiums). P.I.I. will only be disclosed and used by government entities like CMS and are protected by the agent. It is voluntary for a consumer to disclose any P.I.I. to agents or CMS directly.

To make it easier to determine my eligibility for help paying for coverage in future years, I agree to allow the Marketplace to use my income data, including information from my tax returns, for the next 5 years. The Marketplace will send me a notice, let me know of any changes, and I can opt out at any time.

I understand that I'm not eligible for a premium tax credit if I'm found eligible for other qualifying health coverage, like Medicaid, Children's Health Insurance Program (CHIP), or a job-based health plan. I also understand that if I become eligible for other qualifying health coverage, I may owe the Marketplace to end my Marketplace coverage or pay back the premium tax credit. If I don't, the person who files taxes in my household may need to pay back my premium tax credit.

I understand that because the premium tax credit can be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents:

• If my income at the end of 2024 is higher than the amount I put on my application, I may be eligible for a smaller premium tax credit. On the other hand, if my income is higher than expected, I may need to pay back some or all of my premium tax credit.
• I must file a federal income tax return for the 2024 tax year
• No one else will be able to claim me as a dependent on their 2024 federal income tax return
• I claim a person on my return who was enrolled in Marketplace coverage through this application, and whose premium tax credit is paid in whole or in part by advance premium tax credit payments
• If I am married at the end of 2024, I must file a joint or married filing separately return with my spouse

I also agree to the following additional statements:

• I agree to allow the Marketplace to check my Marketplace and Medicare coverage if I am enrolled in both Marketplace and Medicare coverage
• I don't give the Marketplace insurance to end Marketplace insurance for anyone on my application who's enrolled in both Marketplace and Medicare insurance. I understand that they will have a Marketplace health plan without financial help and pay the full cost for their share of the Marketplace plan premium and covered services, if eligible

I'm signing this application under penalty of perjury, which means I've provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information.