Consumer Consent/Intake Form | Synergy Benefit Advisors

Consumer Consent and Authorization Form

ACA Consumer Consent Form

Primary Household Contact's Name(Required)

By signing at the bottom of this Consent Form, I give my permission to Synergy Benefit Advisors, Inc. to serve as the health insurance agency 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 agency to view and use the confidential information provided by me in writing, electronically, or by phone only for one or more of the following:

Searching for an existing Marketplace application
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
Providing ongoing account maintenance and enrollment assistance, as necessary
Responding to inquiries from the Marketplace regarding my application

I understand that the agency will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The agency 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 will remain in effect until I revoke it, and I may revoke or modify my consent at any time by contacting the agency.

Name of Primary Household Contact and/or Authorized Representative:(Required)

Phone Number(Required)

Email Address:(Required)

Physical Address

City

Zip Code

State

I encourage you to also provide information about your medical providers, current prescriptions with the dose and dosage you take, and your preferred pharmacy. This information is optional and not required but without it, I am not able to give you personalized recommendations. When entering your provider information below, please include the first and last name and either their field of specialty or phone number. If you do not have a doctor or do not take any medications, please simply indicate in the text boxes below.

Please enter your Provider's First and Last Name + Practice/Location

Please enter your Prescription + Form (capsule, tablet, etc.) + Dosage

Hidden

Signature:(Required)

Please type your Full Name to use as your Electronic Signature:(Required)

Date:(Required)

Name of Agency: Synergy Benefit Advisors, Inc.
Agency National Producer Number (NPN): 7967997
Owner of Agency: William L. Moore, III
Agency Phone Number: 919-510-5980

Individual Agents:
Bill Moore: NPN: 2377938; Bill@SynergyNC.com
Jonathan Walton: NPN: 22237253; Jonathan@SynergyNc.com
Jody Fortune: NPN: 3890358; Jody@SynergyNC.com