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Authorization for Electronic Assistance - Major Medical

Boone Insurance Associates, Inc.

Authorization for Electronic Assistance - Major Medical

I, , authorize Boone Insurance Associates, Inc. (“BIA”) to take the following actions on my behalf & be agent of record on my behalf:

1. To assist with my Federally-facilitated Exchange (“Marketplace”) account and use my information to review and/or update the account. To assist with eligibility determination in a Qualified Health Plan (“QHP”), including any electronic communications with QHP providers;
2. To access my Personally Identifiable Information (“PII”) for the purpose of assisting with the Marketplace eligibility determination and/or QHP enrollment; and
3. To be listed as the agent of record on my account.

All actions by BIA shall be in accordance with 45 CFR 155.220, and the terms of the Agent Broker General Agreement for the Federally-Facilitated-Facilitated Exchange Individual Market (“General Agreement”) and the Agreement Between Agent Or Broker And the Centers For Medicare and Medicaid Services for the Federally-Facilitated Exchange Individual Market (“IM Agreement”).

I have read and understand the nature of this Authorization. By signing below I am granting the authorization and it is my desire to grant BIA this authority which can be rescinded by me at any point.

Agency: Boone Insurance Associates

Managing Agent: Chris Boone

Managing Agent NPN: 8008427

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Signed by Christopher Boone
Signed On: June 29, 2021

Timestamp

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November 12, 2018 5:21 pm PDT

Authorization for Electronic Assistance - Major Medical Uploaded by Christopher Boone - [email protected] IP 192.168.80.161

November 12, 2018 5:37 pm PDT