Model Consent Form for Marketplace Agents and Brokers

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.

Below are two acceptable versions of the Model Consent Form for Marketplace Agents and Brokers:

To download the original CMS Model Consent Form for Marketplace Agents and Brokers, click here.

To download our design of the Model Consent Form for Marketplace Agents and Brokers, click here.

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