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CMS Consent Form for Marketplace Agents and Brokers 

I, _______________________________________, give my permission to Al Wilson and Skynet Brokers,  Inc to serve as the health insurance agent broker for myself and my entire household if applicable, for  purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By  consenting to this agreement, I authorize the above-mentioned 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: 

• Searching for an existing Marketplace application 

• Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan  or other government insurance affordability programs, such as Medicaid and CHIP or advance  tax credits to help pay for Marketplace premiums; 

• Providing ongoing account maintenance and enrollment assistance, as necessary; or • Responding to inquiries from the Marketplace regarding my Marketplace 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 ensure that my PII is kept private and safe when  collecting, storing, and using my PII for the stated purposes above. 

I confirm that the information I provide for entry on my Marketplace eligibility and enrollment  application will be true to the best of my knowledge. I understand that I do not have to share additional  personal information about myself or my health with my Agent beyond what is required on the  application for eligibility and enrollment purposes. I understand that my consent remains in effect until I  revoke it, and I may revoke or modify my consent at any time by emailing a cancellation notice to


Name of Primary Writing Agent: _____________________________________ 

Alfonzie Wilson 



Agent National Producer Number: ____________________________________ 

Phone Number: ____________________________________________________ 



Email Address: ____________________________________________________ 

Name of Agency (if applicable): ____________________________________________________ 

Skynet Brokers, Inc 

Agency National Producer Number: ____________________________________________________ 

17543688 - 16876486 


Phone Number: ____________________________________________________

Email Address: ____________________________________________________ 

Name of Primary Household Contact 

and/or Authorized Representative: ____________________________________________________ Phone Number: ____________________________________________________ Email Address: ____________________________________________________ 

Signature: ____________________________________________________ 

Date: ____________________________________________________ 

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