Applicant Consent
I authorize the Community Partner Organization listed above (RISE Partnership) to see and use my personally identifiable information (PII) and protected health information (PHI) to help me apply for health insurance. I understand the Community Partner Organization will make sure any stored personal information is kept private and secure. I understand that I may revoke, or otherwise limit, the consent provided with this form at any time. If I do this, I understand that I must notify the Community Partner Organization of the change. I understand that I am responsible for reporting accurate information on this form.
Assister Obligation
The Certified Application Counselor (Assister), in affiliation with the Community Partner Organization, listed above, will:
- Inform me and/or my authorized representative about the full range of Marketplace health coverage options and financial assistance I may qualify for;
- Help me complete my application for health coverage in a Qualified Health Plan (QHP);
- Help me enroll in a QHP and financial assistance (if eligible);
- Help me in the language I prefer or refer me to someone who can;
- Inform me and/or my authorized representative of any potential conflicts of interest.
The Assister will not:
- Charge me and/or my authorized representative any fee for assistance;
- Choose or recommend a health plan for me;
- Discriminate based on age, gender identity, sexual preference, religious or political affiliation, race, color, national origin, or disability.