I hereby authorize Ms. Insurance Group One to act as the health insurance agent or broker for myself and, if applicable, my entire household, for the purpose of enrolling in a Qualified Health Plan through the Federally Facilitated Marketplace.

By granting this authorization, I permit the aforementioned Agent to access and utilize my confidential information provided in writing, electronically, or by phone solely for one or more of the following purposes:

• Searching for an existing Marketplace application
• Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan, or other government assistance programs such as Medicaid, CHIP, or advance tax credits to help pay for Marketplace premiums
• Providing ongoing account support and enrollment assistance, as needed
• Responding to any inquiries from the Marketplace regarding my application

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 take all necessary measures to ensure that my PII is protected and maintained securely during collection, storage, and use for the purposes stated.

I confirm that the information I provide for my Marketplace eligibility and enrollment application is accurate to the best of my knowledge. I also confirm that I have reviewed my completed application and verify its accuracy.

I acknowledge that I am not required to share any additional personal or health-related information with my Agent beyond what is necessary for the eligibility and enrollment process. I understand that my consent remains in effect until I revoke it, and I may do so at any time by contacting my Agent or by revoking it through my HealthSherpa dashboard.