ACA SOA Form

CMS (Centers for Medicare and Medicaid Services) is the governing body that oversees agent compliance in the ACA marketplace. This consent form will allow your insurance agent to do the following:

Conduct searches for your application on the DE/EDE websites in the Marketplace.
Assist in applying for financial assistance if eligible or enrolling in a Marketplace qualified health plan (QHP).
Assist with plan selection and enrollment.
Assist with ongoing account/enrollment maintenance.
Assist with calling the Marketplace Call Center to ask about the status of a Marketplace enrollment or make application changes. Note, the consumer may be required to call the marketplace to give permission for the agent to speak to Marketplace on their behalf.

Beneficiary

First Name

Last Name

Street Address

Street Address (line two)

City

State

Zip Code

Phone Number

Signature

Type your full name I understand this is a legal representation of my signature.

By clicking "Submit", I acknowledge and give consent to the functions and responsibilities of the agent as listed above. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by submitting a request in writing to the agent listed on the form.

Scope of Appointment Confirmation Form

Beneficiary

Signature