Consent Form

Federally-Facilitated Marketplace (FFM) Consent form

The Centers for 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 Plan (QHP). ​

By filling out this form you give Twin Rivers Insurance Inc and its Representatives permission to: ​

    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.