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 By signing below I am granting the authorization and it is my desire to grant BIA this authority which can be rescinded by me at any point.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

Leave this empty:

Signed by Christopher Boone
Signed On: September 25, 2019

Boone Insurance Associates https://booneinsuranceassociates.com
Signature Certificate
Document name: Authorization for Electronic Assistance - Major Medical
Unique Document ID: 36c3bfc0a114941cc7ebee0d6cb0417d2cb33791
Timestamp Audit
November 12, 2018 5:21 pm PSTAuthorization for Electronic Assistance - Major Medical Uploaded by Christopher Boone - [email protected] IP 199.66.198.50
November 12, 2018 5:37 pm PSTmarisa messick - [email protected] added by Christopher Boone - [email protected] as a CC'd Recipient Ip: 199.66.198.50
November 12, 2018 5:41 pm PSTmarisa messick - [email protected] added by Christopher Boone - [email protected] as a CC'd Recipient Ip: 199.66.198.50
November 15, 2018 9:22 am PSTmarisa messick - [email protected] added by Christopher Boone - [email protected] as a CC'd Recipient Ip: 199.66.198.50
April 10, 2019 1:43 pm PSTmarisa messick - [email protected] added by Christopher Boone - [email protected] as a CC'd Recipient Ip: 199.66.198.50
April 10, 2019 1:51 pm PSTmarisa messick - [email protected] added by Christopher Boone - [email protected] as a CC'd Recipient Ip: 199.66.198.50
May 28, 2019 12:59 pm PST Document owner [email protected] has handed over this document to [email protected] 2019-05-28 12:59:31 - 199.66.198.50