Federally-Facilitated Marketplace (FFM) Consent Form

The Centers of Medicare and Medicaid Services (CMS) requires health insurance agents and brokers to obtain a customer's consent prior to helping them apply for a subsidy and/or enroll in a Marketplace Qualified Health Pan (QHP).

1. Apply and enroll for Marketplace (ACA = Affordable Care Act) coverage or financial assistance for you and your family (if applicable)
2. Check the status of your coverage and make updates throughout the year at your request; and
3. Have your permission indefinitely or until you revoke it in writing.