Ambetter Health Insurance – Get Covered – Get ID Card – Get Dental – Get Vision! First Name (required) Last Name (required) Date of Birth (required) Email (required) Zip (required) Phone (required) Mississippi Consent form to assist with Marketplace Health Insurance Plan Yes, I understand by checking below I will allow certified agent access to my Marketplace Account and FREE assistance with reviewing plan information, updating address, updating income, and help maintaining my Marketplace Health Insurance account. Agent can also assist during renewal and anytime information needs updated. In the event my income or household tax filing changes, it is my duty to contact my agent or the Marketplace in a timely manner. I give sole permission to designated FFM Certified agent NPN 16723937 Matt Palka to create, collect, disclose, access, maintain, store, and/or use my Personally Identifiable Information (PII) needed to carry out the roles and responsibilities of a licensed insurance agent and act on my behalf. Agent can conduct a search for my consumer application through the Marketplace and be listed as agent of record on the policy. Agent can also assist with completing an eligibility application, assist with plan selection and enrollment, assist with ongoing account / enrollment maintenance. I understand that I can revoke, limit, or otherwise change the consents I allocate through this form at any time. I can revoke consent in the future by notifying Matt Palka via text or call 615 469 5424. Once I have agreed to this authorization form, I can expect Matt Palka to continue helping me without requiring another authorization form. I understand this service is FREE to me as a legal resident of the United States. YES! I agree to the consent. Please help me with my Marketplace Account.