Please sign below to give us consent to complete you enrollment.


Please Sign at Bottom!


Information to be input into my application which is accurate to the best of my knowlege

First Name -   

Last Name -   

Gender -   

Address -   

City -   

State -   

Zip -  

Phone -   

Email =   

Date of Birth -   

Most recent job -   

Monthly income projected -   

if making less than 138% of the federal poverty limit, I agree to project income at the minimum as I am looking for a job making minimum wage or better -   

I do not have other insurance 

I have provided an accurate SSN - (hidden)

I choose to get me the plan the agent chooses, and I will contact the agent if I need a different plan for any reason.

I input the math problem that robots can't get insurance   

I checked the box yes I give permission to apply for health insurance.  

This is all from the following digital data from my application

IP address -   

Browser -   

Operating system -  




This model form is intended for informational purposes. This form can be personalized by an agent, broker, or agency intending to utilize

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 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.

This model form is intended for informational purposes. This form can be personalized by an agent, broker, or agency intending to utilize the form to collect consumer consent.


OMB Control Number: 0938-1438 Expiration Date: 06/30/2026

CMS Model Consent Form for Marketplace Agents and Brokers

I,                 , give my permission to

             Fenix Insurance Contracting, or Fenix Contracting, 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 a phone call, email, or text from the primary insured, not from another agent asking to takeover.

Name of Primary Writing Agent:

Agent National Producer Number: Phone Number:

Email Address:





Name of Agency (if applicable):

               Fenix Insurance Contracting or Fenix Contracting                                                                                                  

Agency National Producer Number:

              20770889 and 18885304                                                                                                   

Owner of Agency:

             Philip Roesel / Elizabeth Roesel                                                                                                    

Phone Number:


Email Address:


Name of Primary Household Contact and/or Authorized Representative:


Phone Number:


Email Address:








Leave this empty:

Signature arrow sign here

Signature Certificate
Document name: Please Sign at Bottom!
lock iconUnique Document ID: fb3c60b56cc5367d2a92b64e8b191a3198060a96
Timestamp Audit
September 6, 2023 9:58 am ESTPlease Sign at Bottom! Uploaded by Philip Roesel - IP