2022 Privacy Notice and PII Consumer Consent
Important Terms & Conditions, Please Read Carefully:
As required by Centers for Medicare and Medicaid Services (CMS) and the Individual Marketplace and SHOP Privacy & Security Agreements that all agents and brokers must submit a privacy notice to ensure openness and transparency about policies, procedures, and technologies that directly affect consumers’ PII. PII is any information that can be used to distinguish or trace a consumer’s identity (e.g., his or her name, Social Security Number, biometric records) alone or when combined with other personal or identifying information that is linked or linkable to a specific consumer (e.g., date of birth, place of birth, mother’s maiden name).
Filling out this form will give the listed Utah Avenue Insurance Licensed Agent and all Utah Avenue Insurance staff members legal authority to collect your PII for purpose of data verification to submit potential applications to Insurance Carriers through the Marketplace Enhanced Direct Enrollment (EDE) platform and third party platforms in an attempt to gain an insurance policy or limited benefits.
This PII information will be disclosed to applicable Insurance Carriers, Utah Avenue Insurance’s third party technology affiliates, any Utah Avenue Insurance support staff in an effort for processing applications, client supports, Utah Avenue Insurance marketing system, email campaigns, texting campaigns, and other similar uses and platforms as outline by Utah Avenue Insurance now or with future changes and applications in technology.
This request for PII from you is voluntary and not required by law. At any point you may request a copy of your PII information provided in this form which will be provided to you in the most timely manner possible given the time of year demand, or other factors outside of our control.
You are hereby giving permission to:
1) conduct an online "person" search through the marketplace to obtain an existing application,
2) assist with completing an eligibility application,
3) assist with plan selection and enrollment, and
4) assist with ongoing account/enrollment maintenance.
This will include your application for plan year 2022 health insurance as well as any subsequent years in the future until such permission is terminated in writing sent to the address listed for the authorized Agent below.
This notice also serves as a Record of Consumer Consent and is subject to your right of withdrawal. By signing or submitting this form you are agreeing to the outline above as well as all other terms and conditions listed in this form.