I give my permission to RICHARD S RASH to serve as the health insurance agent or 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: 1. Searching for an existing Marketplace application; 2. 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; 3. Providing ongoing account maintenance and enrollment assistance, as necessary; or 4. Responding to inquiries from the Marketplace regarding my Marketplace application.

By submitting this form, you are requesting to have a licensed insurance sales agent contact you on your phone, cell phone or email to provide additional information about Medicare products and services. Your consent is voluntary and allows RICHARD S RASH to contact you via text messaging, artificial or prerecorded voice messages or automatic dialing for marketing purposes. You may contact us to change your preferences and/or opt out at any time. Changing your preferences will not affect your Medicare eligibility for benefits and enrollment, payment for coverage of services or ability to receive medical treatment. Data use charges and rates from your cellular carrier may apply.