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

This model form is intended for informational purposes. This form can be personalized by an agent, broker, web-broker, or agency
intending to utilize the form to collect and document consumer consent, as well as consumer review and confirmation of the accuracy of
eligibility application information the form to collect consumer consent.

OMB Control Number: 0938-1438
Expiration Date: 06/30/2026
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 paying
compensation to the proper agent, broker or web-broker for assisting a particular consumer.
Purpose Statement:
Agents, brokers, and web-brokers assisting consumers with and facilitating enrollment in coverage through
Federally-facilitated Marketplaces (FFMs) and State-based Marketplaces on the Federal Platform (SBM-FPs)
(collectively, Marketplace) or assisting a consumer with applying for advance payments of the premium tax
credit (APTC) or cost-sharing reductions (CSRs) for qualified health plans (QHPs) offered through Exchanges
must document the receipt of consent from a consumer or the consumer’s authorized representative prior
to providing such assistance and must document that eligibility application information has been reviewed
by and confirmed to be accurate by the consumer or the consumer’s authorized representative prior to
application submission. CMS regulations require certain content be included as part of this documentation,
but they do not prescribe the manner in which agents, brokers, and web-brokers must document consumer
consent or consumer review and confirmation of the accuracy of eligibility application information. Instead,
there are different formats of documentation that may be acceptable for agents and brokers to use for
these purposes, such as via a recorded phone call, text message, email, electronic document with digital
signatures, or physical documents with wet signatures. This model consent form serves as an example for
how agents, brokers, and web-brokers may document the receipt of consumer consent and consumer
review and confirmation of the accuracy of eligibility application information via a physical document with
wet signatures.
Since this model consent form is a best practice for documenting the receipt of consumer consent and
consumer review and confirmation of the accuracy of eligibility application information, you may tailor the
form to address the needs of your specific business model. 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 personally identifiable information (PII) to assist the writing agent in enrolling the consumer in
Marketplace coverage for compliance, commissions, or other relevant purposes as you see fit.

PRA Disclosure Statement: 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 09381438. This information collection specifically details what information will be required to be collected and maintained by agents,
brokers, and web-brokers were they to receive a request from HHS for consent records. This information collection will provide HHS
with documentation that may be used for monitoring, audit, and enforcement activities. The time required to complete this
information collection is estimated to take up to 10 minutes per applicant per year, which includes the time to review instructions,
search existing data resources, gather the data needed, to review and complete the information collection. This information
collection is pursuant to 45 C.F.R. §155.220(c)(5), which states that HHS or its designee may periodically monitor and audit an agent,
broker, or web-broker under this subpart to assess its compliance with the applicable requirements of this section. 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, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850, Attention: Information Collections Clearance Officer or
email Brian Gubin at [email protected].

1

This model form is intended for informational purposes. This form can be personalized by an agent, broker, web-broker or agency
intending to utilize the form to collect and document consumer consent, as well as consumer review and confirmation of the accuracy
of eligibility application information.

CMS Model Consent Form for Marketplace Agents, Brokers, Web-brokers, and Agencies
I,
permission to

[insert name of consumer or consumer’s authorized representative], give my

[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/State-based Marketplace on the
Federal Platform. By providing my consent, I authorize the above-mentioned (pick applicable and delete the
rest: agent/broker/web-broker/agency) to view and use the confidential information, including personally
identifiable information (PII), 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 an
application for government insurance affordability programs, such as Medicaid and CHIP or advance
payments of the premium tax credit 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 (pick applicable and delete the rest: agent/broker/web-broker/agency) will not use or share
my personally identifiable information (PII) for any purposes other than those listed above. The (pick one and
delete the rest: agent/broker/web-broker/agency) will ensure that my PII is protected when creating, collecting,
disclosing, accessing, maintaining, storing, and using my PII for the stated purposes above.

I understand that I do not have to share additional PII or protected health information (PHI) with my (pick one
and delete the rest: agent/broker/web-broker/agency) beyond what is required on the Marketplace
application for eligibility and enrollment purposes. I understand that my consent remains in effect until [insert
duration of consent], and I may revoke or modify my consent at any time by [insert method to revoke
consent].
Name of Primary Writing
Agent/Broker/Web-broker:
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:

2

CMS Model Eligibility Application Review Form for Marketplace Agents, Brokers, Web-brokers, and Agencies
I,
[insert name of consumer or consumer’s authorized representative], have reviewed the
Marketplace eligibility application information and confirmed its accuracy prior to the application being
submitted. The (pick one and delete the rest: agent/broker/web-broker) explained the attestations at the end of
the eligibility application to me prior to the application being submitted and I was given an opportunity to ask
questions about them.
I understand that the (pick applicable and delete the rest: agent/broker/web-broker/agency) will not use or share
my personally identifiable information (PII) for any purposes other than those to which I consented. The (pick
applicable and delete the rest: agent/broker/web-broker/agency) will ensure that my PII is kept private and safe
when creating, collecting, disclosing, accessing, maintaining, storing, and using my PII for the purposes I consented
to. I understand that I do not have to share additional PII or protected health information (PHI) with my (pick
applicable and delete the rest: agent/broker/web-broker/agency) beyond what is required on the Marketplace
application for eligibility and enrollment purposes.
Name of Primary Writing
Agent/Broker/Web-broker:
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:

3

Model Consent Verbal Script
The following is a script that can be used to meet the consent documentation requirements when assisting a
Marketplace consumer over the phone. This model script, as written, is intended to be used when consent is
being granted to a single agent, broker, or web-broker but may be updated to reflect consent being granted to a
broader set of persons, if/when appropriate. The conversation should be recorded, where permitted under state
law, and producible to CMS upon request. This script must be read at the beginning of the conversation with the
consumer as consent needs to be obtained prior to assisting a consumer with an application or enrollment for
Marketplace coverage.
Agent: “Hello, my name is [say your name]. Today is [say today’s date, including month and year] Who am I
speaking with today?”
Agent: “Do I have your permission to create, collect, disclose, access, maintain, and store your personal
information to assist you with applying for and enrolling in a Qualified Health Plan offered on the Federallyfacilitated Marketplace/State-based Marketplace on the Federal Platform Your permission would grant me the
ability to:
• Search for an existing Marketplace application;
• Complete an application for eligibility and enrollment in a Marketplace Qualified Health Plan or an
application for government insurance affordability program, such as Medicaid and CHIP or advance
payments of the premium tax credit to help pay for Marketplace premiums;
• Provide ongoing account maintenance and enrollment assistance, as necessary; and
• Respond to inquiries from the Marketplace regarding your Marketplace application
Agent: “Thank you. The consent you just granted remains in effect until [insert duration of consent]. You may
revoke your consent at any time by [state how the consumer may revoke their consent].”

4

Model Eligibility Application Review Verbal Script
The following is a script that can be used to meet the requirements related to the review and confirmation of the
accuracy of eligibility application information when enrolling a consumer over the phone. The conversation
should be recorded, when allowed under state law, and producible to CMS upon request. This script must be read
prior to submitting the consumer’s Marketplace application or enrollment.
Agent: “Hello, my name is [say your name]. Today is [say today’s date, including month and year] Who am I
speaking with today?”
Agent: “Let me discuss the attestations at the end of the eligibility application. [Explain the attestations to the
consumer]. Do you have any questions about the attestations I just explained?”
Agent: “Let's review the information you provided during this conversation on your eligibility application before I
submit to confirm it is accurate and complete. [Review the information on the eligibility application with the
consumer]. Have you reviewed the information on the eligibility application and confirmed it is accurate?”

5