We are your trusted independent brokerage for superior coverage in Florida and Georgia. Our client-focused approach simplifies insurance, offering tailored policies following personalized risk assessments. Backed by industry expertise, we ensure reliable, satisfying coverage. Choose Lifeline Insurance Group for comprehensive and personalized insurance solutions with a commitment to excellence.

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+1 (305)-677-9912

+1 (786)-319-7679

Health Insurance Enrollment Consent Authorization


Health Insurance Enrollment Consent Form

Name of Primary Writing Agent

Agent National Producer Number

Phone Number
305.677.9912 / 786.319.7679

E-mail address

Name of Agency

Agency National Producer Number

Owner of Agency

Phone Number

E-mail address

Get ready for the 2023-2024 enrollment phase. The CMS introduced new guidelines to fight insurance fraud. These rules apply to agencies and brokers like us, making insurance safer for everyone.

One significant change involves your consent. It’s crucial when we help you on the Marketplace platform, like applying for subsidies or enrolling you in a plan. Your authorization lets us assist you effectively, please grant your consent by filling out the form below.

OMB Control Number: 0938-1438
Expiration Date: 06/30/2026

I give my permission to EDUARDO LUIS DOMINGUEZ, 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. 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. Searching for an existing Marketplace application;

2. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits 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 Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.

I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the 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 contacting LIFELINE INSURANCE GROUP by email at eddy@lifelineins.com or by text message at 786.319.7679.

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Name of Primary Household Contact and/or Authorized Representative
Date of Birth

You will receive a copy of this consent form by e-mail.

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