CONSENT FORM FOR GEORGIA ACCESS ENROLLMENT
By Completing the below form, I give my permission to Kirk Lewis with Quality Employee Benefits Agency 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 Georgia State-based Exchange (Georgia Access).
Name of Primary Writing Agent: Kirk Lewis
Agent National Producer Number: 11464507
Phone Number: 423-499-2962 (office) | 423-305-2319
Email Address: Klewisins@gmail.com
Name of Agency (if applicable): Quality Employee Benefits
Owner of Agency: Kirk Lewis
By Completing this form, I give my permission to Kirk Lewis (NPN 11464507) with Quality Employee Benefits Agency (423-499-2962) / klewisins@gmail.com 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 Georgia State-based Exchange (Georgia Access). 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) I give permission to access my information for the purpose of helping me complete an application for eligibility and enrollment in a Qualified Health Plan or other insurance affordability programs, such as Medicaid and PeachCare for Kids (CHIP) or advance tax credits to help pay for insurance premiums. 2) I agree that I have been informed and agree with all the disclaimers included in my exchange application. 3) I understand the plan(s) I am being enrolled in and agree that I wish to be enrolled in that plan; I understand that I may cancel the delegation at any time either within the Georgia Access portal, a certified partner portal, or by calling the Georgia Access contact center at 1-888-687-1503. 4) I give the agent and any member of their agency permission to assist me in maintaining my information and changing my plans in the future without requiring consent. I understand that I am not obligated to provide this consent, but if I do not, I will need to document a new consent every time I require future assistance from my agent.