Form CMS-10494 Recertification Request Form

Model Certified Application Counselor (CAC) Recertification Request Form
for Federally-facilitated and State Partnership Marketplaces
TO BE COMPLETED BY CAC DESIGNATED ORGANIZATION:
1) CAC designated organization (CDO):

2) Organization Designee ID:

_____________________________________________

________________________

3) Financial, business, or contractual relationships organization has or expects to have with
health insurance companies that offer qualified health plans (QHPs) or with insurance
affordability programs (e.g., Medicaid, CHIP, APTCs/CSRs), or other potential nondisqualifying
conflicts of interest: 1 [note to CDO: complete if organization is fulfilling its duty, as required by
45 CFR 155.225(d)(2), to inform consumers of any existing or anticipated relationships it has
with QHPs or insurance affordability programs or other potential conflicts of interest through
its individual CACs]

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
TO BE COMPLETED BY INDIVIDUAL STAFF OR VOLUNTEER:

4) Individual CAC Name:

_____________________
7) Location(s) in which I
provide or will provide
CAC services:

__________________________
__________________________
__________________________

5) Unique ID Number:

__________________________

6) Date of Initial
Certification:
____________________

_____________________
_____________________
_____________________

________________________
________________________
________________________

_____________________
_____________________
_____________________

________________________
________________________
________________________

8) Languages spoken,
other than English: __________________ ___________________ _____________________

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Effective July 28, 2014, an individual or entity has a disqualifying conflict of interest and cannot become or
continue to serve as a CAC or CAC designated organization, if the individual or entity receives any consideration
directly or indirectly from a health insurance or stop loss insurance issuer in connection with the enrollment of any
individuals in a QHP or non-QHP. In a Federally-facilitated Marketplace, however, no health care provider shall be
ineligible to operate as a CAC or CAC designated organization solely because it receives consideration from a
health insurance issuer for health care services provided. 45 CFR 155.225(g)(2).

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9) My availability to provide CAC services:

M: ________________________________________
T: ________________________________________
W: ________________________________________
Th: ________________________________________
F: _________________________________________
Sa: ________________________________________
Su: ________________________________________

10) Date of Achieving a Passing Score
on 2015 CAC Training:

_________________________
Proof of training attached? (select one)
YES

NO

11) Financial, business, or contractual relationships I have or expect to have with health insurance
companies that offer qualified health plans or with insurance affordability programs (e.g.,
Medicaid, CHIP, APTCs/CSRs), or other potential nondisqualifying conflicts of interest: 2

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

12) Individual’s signature
•
•
•
•
•
•

13) Date:

_________________________________________________________
By signing this form, I affirm that I wish to be recertified as a CAC.
I understand that my CDO may review my work as a CAC for the CDO
as a part of the recertification process.
I understand that I must complete annual CAC training before the
anniversary date of my initial certification and provide proof of my
successful completion to my CDO.
I understand that my training certificate is not my official CAC
certificate, and that my CDO will issue a new official CAC certificate to
me if it recertifies me.
I understand that in order to be recertified, I may be required to sign
and enter into a new agreement with my CDO. My CDO will inform me
whether a new agreement is necessary.
I understand that if my CDO does not recertify me, I must adhere to
the termination provisions of my agreement with my CDO that apply,
including those that prohibit me from holding myself out as a CAC and
require me to protect personally identifiable information (PII).

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_________________

Effective July 28, 2014, an individual or entity has a disqualifying conflict of interest and cannot become or continue to serve
as a CAC or CAC designated organization, if the individual or entity receives any consideration directly or indirectly from a
health insurance or stop loss insurance issuer in connection with the enrollment of any individuals in a QHP or non-QHP. In a
Federally-facilitated Marketplace, however, no health care provider shall be ineligible to operate as a CAC or CAC designated
organization solely because it receives consideration from a health insurance issuer for health care services provided. 45 CFR
155.225(g)(2).

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