ACA / HEALTH INSURANCE MARKETPLACE
CONSUMER CONSENT AND AGENT AUTHORIZATION AGREEMENT

Agency: AJ & Partners Group Corp.  ·  Assigned Agent: Alejandra Fernandez  ·  NPN: 18823272

Consent and Authorization

I, the undersigned consumer, voluntarily authorize Alejandra Fernandez, NPN 18823272, of AJ & Partners Group Corp., to assist me with my health insurance application through the Centers for Medicare & Medicaid Services (CMS), Health Insurance Marketplace / HealthCare.gov, and an authorized enrollment platform, including an Enhanced Direct Enrollment (EDE) platform when applicable.

I understand that I am requesting the assistance of the agent named above and authorize her to access, review, evaluate, and use the information necessary to assist me with my Marketplace eligibility application and health insurance enrollment.

I authorize Alejandra Fernandez to assist me with the following activities:

• Review my existing Marketplace application and enrollment information.
• Assist me in completing a new application, renewal, or re-enrollment.
• Review and update information I provide concerning my household, address, contact information, income, tax household, immigration documentation, and other Marketplace eligibility information.
• Review available health insurance plans, premiums, deductibles, copayments, provider networks, prescription benefits, and other plan information.
• Provide plan recommendations based on the information and preferences I provide.
• Assist me with determining potential eligibility for Advance Payments of the Premium Tax Credit (APTC) and Cost-Sharing Reductions (CSR), when applicable.
• Assist me in selecting and completing enrollment in the health plan that I authorize.
• Submit my Marketplace application and enrollment after I have reviewed and confirmed that the information is accurate.
• Assist me with future corrections, updates, document requests, Data Matching Issues, Special Enrollment Period verification, or other Marketplace matters related to my coverage during the authorized period.

Consumer Participation

• I confirm that I am personally participating with the agent during the application, registration, renewal, re-enrollment, or changes being made to my Marketplace account.
• I understand that the agent will not knowingly make changes to my application or health plan without my authorization.
• I authorize the agent to view and discuss available plans with me, provide recommendations, and complete the enrollment process based upon the plan and information that I approve.
• I understand that the final decision regarding which health insurance plan I select is mine.

Accuracy of Information

• I understand that I am responsible for providing complete and truthful information.
• Before my Marketplace application is submitted, I will be given the opportunity to review the information entered on my application.
• By signing this agreement, I confirm that I have reviewed the information discussed with the agent and that, to the best of my knowledge, the information I have provided is true and accurate.
• I understand that inaccurate information regarding income, household composition, tax status, immigration status, or other eligibility information may affect my health insurance eligibility, premium tax credit, cost-sharing reductions, or other Marketplace benefits.

Privacy and Personal Information

I authorize Alejandra Fernandez and AJ & Partners Group Corp. to access and use my personally identifiable information only as reasonably necessary to assist me with my Marketplace application, enrollment, servicing, and related health insurance matters.

This authorization does not permit the agent to knowingly provide false information, change information without my approval, or enroll me in a health plan that I have not authorized.

Duration of Authorization

This authorization applies to assistance related to my 2027 Marketplace health insurance coverage, including enrollment, renewal, and necessary updates during the applicable coverage year, unless I revoke my consent earlier.

I understand that additional Marketplace or CMS authorization may be required for a future plan year.

Right to Revoke Consent

I may revoke this authorization at any time by notifying Alejandra Fernandez / AJ & Partners Group Corp. by telephone, email, or written notice.

Revocation will apply to future actions and will not invalidate actions that I previously authorized.

Consumer Acknowledgment

By signing below, I confirm that:

• I requested the assistance of Alejandra Fernandez.
• I authorize her to assist me with my ACA / Marketplace application and enrollment as described above.
• I have had the opportunity to ask questions.
• I understand the information contained in this agreement.
• I understand that my signature documents my consent and authorization for the agent to assist me.