I give my permission to Selected Benefits, Inc., iSure, LLC, AO Insurance Agency, Inc and any of its' currently licensed Writing Agents, including, but not limited to, (Steven Wendlandt, Philip Raskin, Jordan Garren, Shyanne Diaz, Melanie Ladner, and Tamara Blanch Blake 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 agencies and agents 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 agencies or agents will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The agencies or agents 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 agencies or agents beyond what is required on the Marketplace 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 sending an email to
info@selectedbenefits.com.
Steven Wendlandt / NPN 7437846 / Phone: 713.822.5855 /
stevew@selectedbenefits.com Philip Raskin / NPN 8473402 / Phone: 832.878.5951 /
phil@isurellc.com Jordan Garren / NPN 17726568 / Phone: 832.493.2100 /
jordan@isurellc.com Shyanne Diaz / NPN 20981989 / Phone: 281.345.0805 /
shyanne@isurellc.com Melanie Ladner / NPN 15789746 / Phone: 281.606.9670 /
melanie@isurellc.com Tamara Blanch Blake / NPN 20054579 / Phone: 914.843.5536 /
tamara@isurellc.com _____________________________________________________
Selected Benefits, Inc. / NPN 14657307
Owner: Steven Wendlandt / Phone: 713.822.5855 /
info@selectedbenefits.com iSure, LLC / NPN 16165380
Managing Member: Philip Raskin / Phone: 832.878.5951 /
phil@isurellc.com