NP Short V2 – Site Title

Healthcare.gov Enrollment Marketplace Validation Form

Enroll in subsidized healthcare and benefits by submitting this form!

Primary and Household Information

First Name

Last Name

Street Address 1

City

State

Zip

Gender

Male

Female

Email

Phone Number

Primary Date of Birth

Please type your full name to agree and submit below:

Date

I hereby grant permission to Nino Palermo NPN 19623606 and The Palermo Group and their agent partners to act as the health insurance agent or broker for myself and, if applicable, my entire household, for the purposes of enrolling in a Qualified Health Plan offered on the Federally Facilitated Marketplace, specifically at the minimum income required to qualify in my state. By signing this agreement, I authorize the aforementioned Agent to access, view, and utilize the confidential information supplied by me, whether in writing, electronically, or over the phone, exclusively for the following activities: Searching for an existing Marketplace application; Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan, other government affordability insurance programs like Medicaid, CHIP, or advance tax credits to assist with Marketplace premiums; Providing continuous account maintenance and required enrollment support; Responding to inquiries from the Marketplace concerning my application.

I acknowledge and understand that Nino Palermo NPN 19623606 and The Palermo Group and their affiliates will not employ or disseminate my personally identifiable information (PII) for reasons other than those specified above. The agency commits to ensuring the confidentiality and security of my PII during its collection, storage, and use for the described objectives. I affirm that all the details I supply for my Marketplace eligibility and application are accurate to the best of my understanding. I recognize that I am not obligated to provide any additional personal or health-related data to my Agent beyond what the application demands for eligibility and registration. My consent will remain valid unless I choose to revoke it, and I retain the right to withdraw or adjust my consent by reaching out to Nino Palermo NPN 19623606 by Email only at any moment. I hereby attest that all the information provided is true and accurate to the best of my knowledge and grant Nino Palermo NPN 19623606 and The Palermo Group and their affiliates permission to process my application based on the information shared.