Consent Form for Marketplace Agents and Brokers
By digitally signing this document, I give my permission to Jeffrey Mercado to serve as the health insurance agent or broker for myself and my entire household, if applicable, for the purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace.
Authorization of Use of Information
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 programs such as Medicaid, CHIP, or advance tax credits.
- Providing ongoing account maintenance and enrollment assistance.
- Responding to inquiries from the Marketplace regarding my application.
Data Privacy and Security
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 secure when collecting, storing, and using it. For details on how your data is collected, stored, and used, please review our Privacy Policy and Terms of Service.
Consent to Communication
By submitting this form, I agree to receive marketing calls and text messages from 360 Universal Solutions LLC DBA 360 Universal Healthcare at the phone number I provided, including via automated technology. Consent is not a condition of enrollment. Message and data rates may apply. I may revoke my consent at any time by replying STOP to text messages or by contacting the agency directly.
Revocation of Consent
I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by phone, email, or USPS.
Agency and Agent Details
Agency: 360 Universal Healthcare
Primary Writing Agent: Jeffrey Mercado
Agent NPN: 11206123
Phone: (727) 417-5534
Email: jeff@getcoveredusa.org