I give my permission to The Rathbun Agency to act as my legal Marketplace authorized representative, to create, collect, disclose, access, maintain, use, and/or store my personally identifiable information and/or the personally identifiable information of my authorized representative and to perform the following duties as my agent/agency:

• Inform me and/or my authorized representative about the full range of Marketplace health coverage options and insurance affordability programs for which I’m eligible
• Help me complete my application for health coverage in a Qualified Health Plan (QHP) through the Marketplace and for insurance affordability programs
• Help me enroll in a QHP or in an insurance affordability program

I understand that I may revoke this authorization at any time and will notify the Agent/Agency if I choose to revoke my authorization. My agent is not responsible for any penalties I incur as a result of misstating my projected income.

I understand the Agent/Agency has the following responsibilities and will perform the following functions:

• Privacy will be maintained in accordance with the Health Insurance Portability and Accountability Act (HIPAA)
• Will inform me and/or my authorized representative about the full range of Marketplace health coverage options and insurance affordability programs for which I am eligible
• Will help me apply and enroll for health coverage in a QHP through the Marketplace and for insurance affordability programs
• The representative acknowledges that they cannot choose a health insurance plan for me and is required to act in my best interest