Let me check your eligibility and health plan options in the marketplace

By submiting this form, I authorize the Licensed Insurance Agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following:

1. Run an initial health plan offering search at my location, for me and/or my household as filled, with the information provided.

2. To contact me via phone call or email with the search results or further questions for my best interest to obtain health coverage through the Marketplace.

   I understand that the search could only be performed at the states where agent claims to hold a valid Health Insurance license.

   My information will not be shared or sold to third parties for marketing or any other purpose.

For Medicare use the contact form found here (click)

Compliance rules issued by Marketplace and/or the Centers for Medicare and Medicaid Services (CMS), require that all insurance agents must obtain and save consent from the consumers in order to perform an eligibility/plan options check prior to run a search.