Health Insurance Questionnaire

The Centers for Medicare & Medicaid (CMS) require us to document your permission for us to assist you with obtaining health insurance coverage through the Health Insurance Marketplace.  If the first section (Marketplace Authorization) does not apply to you, this form will not be retained.  You may cancel this authorization at any time by contacting us.

We use text messaging to facilitate timely communications with our clients.  Please see our Privacy Policy for our promise to you to safeguard your information.  You may opt out of text messaging at any time.


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