Consent and Scope of Appointment
Primary Agent: Kayla Price
NPN: 18530055
FFM: kprice19
Price Services Group, L.L.C.
PO Box 1628, Clinton, NC 28329
Agency Owner: Kayla Price
Phone: 866-648-1578
Email: [email protected]
Important information to know
1. Please don't hesitate to contact us before contacting the Marketplace. We strive to make things easier for you and often can answer the questions without the long hold time, the confusion, and the mistakes.
2. Try to ignore the emails from healthcare.gov regardless of how they are worded. Call us at any time for help.
3. You might get an email from healthcare.gov stating "Pay your premium right now. Log in and pay or you will get canceled." Healthcare.gov doesn't know if you paid or not until the insurance carrier tells them. And you can't log into healthcare.gov to pay. Payments are done directly with the insurance company you are enrolled with.
4. You can adjust your estimated income anytime throughout the year. Just contact us and we will get it done quickly and efficiently. Remember, when you file your taxes, the IRS will compare what is on the application vs what is on your tax return. You may have to pay back any overpayment of the tax credit if your income is higher than was reported on the application.
5. Questions about who is covered in your network and who is not, need to be addressed to the insurance company directly. They can also answer questions about policy, deductibles, and co-pays throughout the year.
6. Please give us any requested documents instead of mailing them to the Marketplace. Mailing them can lead to longer times of approval and hardcopies have been lost. We will scan them and attach them directly to your account. We will also alert you to any changes that might need to be made to your income based on these documents.
7. Open all regular mail that comes from Healthcare. gov. If you are confused by the paperwork, please call us, but never throw it away without opening it. Important information is mailed to you including your 1095 forms that you will need in order to complete filing your taxes.
8. Someone may call you from healthcare.gov. If that happens, ask what information they need and tell them you will contact your agent to complete it. That way you will avoid the few scams that are out there. We are always happy to help!
9. You understand that Price Services Group, L.L.C., and all staff within that agency are working on your behalf.
10. The policy requires that consumer documentation about their consent and review and confirmation of their eligibility application be collected from agents, brokers, and web brokers as needed. Therefore, this information must be collected year-round and provided to HHS once annually if it so chooses.
I understand that I’m not eligible for a premium tax credit if I'm found eligible for other qualifying health coverage, like Medicaid, Children’s Health Insurance program (CHIP), or a job-based health plan. I also understand that if I become eligible for other qualifying health coverage, I must contact Price Services Group, L.L.C. and/ the Marketplace to end my Marketplace coverage and premium tax credit If I don’t, the person who files taxes in my household may need to pay back my premium tax credit. I understand that because the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents:
I must file a FEDERAL income tax return for the tax year in which I have coverage.
If I'm married at the end of the current year, I must file a joint income tax return with my spouse.
I must report any income changes throughout the year to prevent any issues with taxes.
I also expect that:
No one else will be able to claim me as a dependent on their Federal income tax return.
I’ll claim a personal exemption deduction on my Federal income tax return for any individual
listed on this application as my dependent who is enrolled in coverage through this Marketplace, and whose premium for coverage is paid in whole or in part by advance payments of the premium tax credit.
If any of the above changes:
I understand that it may impact my ability to get the premium tax credit. I also understand that when I file my Federal Income tax return for this year, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I understand that if the income on my tax return is lower than the amount of income on my application, I may become eligible to get additional premium tax credit amount. On the other hand, if the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax.
I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information.
By signing below, I give permission to Price Services Group, L.L.C. to:
Search for an existing Marketplace application
Complete enrollment
Provide ongoing account maintenance and enrollment assistance, as necessary; or
Respond to inquiries from the Marketplace regarding my application.
This permission is granted for me, my spouse or any other household member listed on the application in the plan that we have listed.
I understand that the Agent will not use or share my personally identifiable information for any purpose 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 understand that my consent remains in effect untiI I revoke it, and I may revoke or modify my consent at any time by sending a request to revoke consent to [email protected] that must be dated and signed.
Legal Disclosure: The contents of this document do have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law. This model consent form will not supersede any State Agent of Record, Broker of Record, or other form required by a QHP issuer for purposes of making commission payments to the proper agent or broker for assisting a particular consumer.
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 services as an example of how agents and brokers may document consent via a physical document with wet signatures.