ACA / Marketplace Short Form

Primary Applicant

Street Address

City, State, Zip

Phone Number

Married or Single?

Who is Applying? Including Self. List Date Of Birth and Social Security Number?

U.S. Citizen?

Who Are Your Dependents NOT Applying for Coverage? This is Needed to Determine a Subsidy

Who is Working?

Employer?

Estimated Household Income for Current Year

Does your employer or your spouses employer offer health insurance?

Filing Federal Tax Return? You must file a federal tax return to receive a subsidy.

Yes

As the primary contact for this application, I give my permission to
Arthur Kyle Romanat of Health Market Genius, LLC 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 contacting The Health Insurance Marketplace at 800 318 2596.

Name of Primary Writing Agent: Arthur Kyle Romanat
Agent National Producer Number: 6545870
Phone Number: 828 266 1369
Email Address: kyle@healthmarketgenius.com
Name of Agency (if applicable): Health Market Genius, LLC
Agency National Producer Number: 19083605

Owner of Agency: Arthur Kyle Romanat
Phone Number: 828 266 1369
Email Address: kyle@healthmarketgenius.com

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