I give my permission to Homeland Insurance LLC (info@homeland-insurance.com / (832) 861 1131 / NPN 19656924) and its agents Khizar Rais (NPN 18751066) or Fahed Shah (NPN 17370790) 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/State-based Marketplace on the Federal Platform. By providing my consent, I authorize the above-mentioned agent/broker/web-broker/agency to view and use the confidential information, including personally identifiable information (PII), provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following:1. Searching for an existing Marketplace application; 2. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or an application for government insurance affordability programs, such as Medicaid and CHIP or advance payments of the premium tax credit to help pay for Marketplace premiums; 3. Providing ongoing account maintenance and enrollment assistance, as necessary; or 4. Responding to inquiries from the Marketplace regarding my Marketplace application.I understand that the agent/broker/web-broker/agency will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The agent/broker/web-broker/agency will ensure that my PII is protected when creating, collecting, disclosing, accessing, maintaining, storing, and using my PII for the stated purposes above. I understand that I do not have to share additional PII or protected health information (PHI) with my agent/broker/web-broker/agency beyond what is required on the Marketplace application for eligibility and enrollment purposes. I understand that my consent remains in effect until 1/1/2030, and I may revoke or modify my consent at any time by emailing info@homeland-insurance.com

 

I have reviewed the Marketplace eligibility application information and confirmed its accuracy prior to the application being submitted. The agent/broker/web-broker explained the plan details and attestations at the end of the eligibility application to me prior to the application being submitted and I was given an opportunity to ask questions about them. I understand that the agent/broker/web-broker/agency will not use or share my personally identifiable information (PII) for any purposes other than those to which I consented. The agent/broker/web-broker/agency will ensure that my PII is kept private and safe when creating, collecting, disclosing, accessing, maintaining, storing, and using my PII for the purposes I consented to. I understand that I do not have to share additional PII or protected health information (PHI) with my agent/broker/web-broker/agency beyond what is required on the Marketplace application for eligibility and enrollment purposes.

 

By proceeding, I authorize Homeland Insurance and its agents to serve as my Agent of Record (AOR). I authorize Homeland Insurance and its agents to re-enroll me next open enrollment when my plan comes up for re-enrollment. If the same plan is not available during re-enrollment, I authorize Homeland Insurance and its agents to cross-walk me onto another plan. If my agent is unable to submit my application directly, I consent to their guidance in completing and submitting it myself through their EDE (Enhanced Direct Enrollment) marketing link. I permit my agent to assist with plan selection, enrollment, and ongoing policy support.