CMS-10840 CMS Model Consent Form for Marketplace Agents and Broker

Legal Disclosure:
The contents of this document do not have the force and effect of law and are not meant to bind the public in
any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the
public regarding existing requirements under the law. This model consent form will not supersede any State
Agent of Record, Broker of Record, or other form required by a QHP issuer for purposes of making commission
payments to the proper agent or broker for assisting a particular consumer.
Purpose Statement:
Registered agents and brokers assisting consumers apply for and enroll in Marketplace coverage must document
consumer consent prior to accessing or updating their Marketplace information. CMS does not prescribe the
manner in which agents and brokers must document consent. Instead, there are different formats that may be
acceptable for agents and brokers to use to document consumer consent, such as via a recorded phone call, text
message, email, electronic document with digital signatures, physical document with wet signatures, etc. This
model consent form serves as an example for how agents and brokers may document consent via a physical
document with wet signatures.
Since this model consent form is a best practice for obtaining consumer consent, you may tailor the form to
address the needs of your specific business model in addition to meeting the CMS requirement to document
consent from a consumer prior to assisting the consumer enroll in coverage in the Marketplace, including prior
to conducting a person search. For example, if an Agency is involved, you may clarify specifically who else within
the Agency other than the writing Agent is able to view and use the consumer’s PII to assist the writing Agent in
enrolling the consumer in Marketplace coverage for compliance, commissions, or other relevant purposes as
you see fit.

OMB Control Number: 0938-XXXX
Expiration Date: XX/XX/20XX
CMS Model Consent Form for Marketplace Agents and Brokers
I, ____________________ [insert name of primary household contact], give my permission to
____________________ [insert name of the person or entity who has the consumer’s consent] to serve as the
health insurance agent or broker for myself and my entire household if applicable, for purposes of enrollment in
a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I
authorize the above-mentioned Agent to view and use the confidential information provided by me in writing,
electronically, or by telephone only for the purposes of one or more of the following:
1. Searching for an existing Marketplace application;
2. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other
government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help
pay for Marketplace premiums;
3. Providing ongoing account maintenance and enrollment assistance, as necessary; or
4. Responding to inquiries from the Marketplace regarding my Marketplace application.
I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes
other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing,
and using my PII for the stated purposes above.
I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will
be true to the best of my knowledge. I understand that I do not have to share additional personal information
about myself or my health with my Agent beyond what is required on the application for eligibility and
enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or
modify my consent at any time by _________________________________ [insert method to revoke consent].
Name of Primary Writing Agent:
Agent National Producer Number:
Phone Number:
Email Address:

____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________

Name of Agency (if applicable):
Agency National Producer Number:
Owner of Agency:
Phone Number:
Email Address:

____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________

Name of Primary Household Contact
and/or Authorized Representative:
Phone Number:
Email Address:
Signature:
Date:

____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________

PRA DISCLOSURE: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX, expiration date is XX/XX/20XX. The time required
to complete this information collection is estimated to take up to 0.08 hours per applicant per year, including the time to review instructions, gather the
information needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing
sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden
approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns
regarding where to submit your documents, please contact Brian Gubin at [email protected].