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ACA Consent Form

ACA Constent Form

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I give my permission to my agent, Jon Nolan, 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:
  • Searching for an existing Marketplace application
  • 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
  • Providing ongoing account maintenance and enrollment assistance, as necessary
  • 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 an 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 my Agent.
Name of Writing Agent: Jon Nolan
Agent National Producer Number: 17530407
Phone Number: 817-521-6777
Email Address:
Type NONE or N/A if there is no Authorized Representative
* If listing Authorized Representative, all contact information and Signature must belong to that person. However, Name of Primary Household Member must also be listed on the line above.
This field is for validation purposes and should be left unchanged.

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Customer Reviews

Would recommend him to my family and friends.

Jacqueline O

Jon is absolutely fantastic to work with.

Kelly W

Jon always has time to help me. He knows health insurance so well.

Alice J

I appreciate his professional and personal approach.

James M

He's knowledgeable, trustworthy, patient, kind, and very professional.

Noleak H