My Rights as a Patient

By signing this form, I, give consent to from Lapeira & Associates LLC to serve as the health insurance agent or broker, as my Agent of Record, for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace.

By signing this form, I grant permission to and/or their staff to provide the following services on behalf of myself, and my entire household if applicable to keep my application and health coverage in good standing:

1. Search for a new or existing Marketplace application.
2. Completing an application for eligibility and enrollment in a marketplace Qualified Health Plan or government insurance affordability programs, such as Medicaid and CHIP, Marketplace Direct Enrollment Classic/Enhanced Direct Enrollment websites, or advance tax credits to help pay for Marketplace Premiums or enrollment in off-exchange insurance products as applicable.
3. Providing ongoing account maintenance, enrollment assistance, information on plan benefits, new products, the benefits of new products, and payment transactions as necessary.
4. Responding to inquiries from the Marketplace regarding my Marketplace application.
5. Communication consent (TCPA Compliance): I, , consent to receive communications from Lapeira & Associates LLC regarding health insurance options, benefits, insurance products, policy updates, premiums, applications, and related matters through phone calls, emails, SMS messages, and other forms of communication to assist me or remind me of any action necessary to keep my policy in good standing. I understand that such communications may involve the use of automated systems or with prerecorded voice messages from Lapeira & Associates LLC at your provided number. By providing my contact information with my electronic signature, when I click the "submit" button, I agree to Lapeira & Associates LLC . Terms of Use. This consent includes agreeing to resolve any Telephone Consumer Protection Act claims by arbitration. This applies even if your number is on a do-not-call list. Agreeing to these calls or texts is not required to buy goods or services from us. When receiving a text message, you can reply YES to receive updates and information about your policy from Lapeira & Associates LLC You can also reply HELP for help. Msg & data rates may apply. Up to 5 msgs/month. Reply STOP to opt-out at any time. For more information about our Privacy Policies click here: https://lapeirainsurance.com/privacy-policy/. For more information about our Terms of Use click here:: https://lapeirainsurance.com/terms-of-use/.

I understand that my Agent of Record will not use or share my personally identifiable information (PII) for any purposes other than those listed above. Additionally, my Agent of Record 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 the information I provide to my Agent of Record will be used or disclosed ONLY to provide information or assist me with or facilitate enrollment through a Federally-Facilitated Exchange, including to searching for a current application using an approved Classic Direct Enrollment (DE) or Enhanced Direct Enrollment (EDE) website (Marketplace).

Acknowledgment of Accurate Information and Non-Misrepresentation

By signing this form, I affirm and acknowledge that I have been fully informed and provided with a clear explanation regarding the following:

1. The specific benefits included in the healthcare plan, including any insurance coverage or associated benefits.
2. Whether the healthcare plan I am enrolling in is considered a major or comprehensive medical insurance plan, or is equivalent to such insurance coverage.
3. The true and accurate costs associated with the healthcare plan, including premiums, deductibles, and other financial obligations.

Furthermore, I confirm that I have not been offered or promised any free offers, cash rewards, rebates, or other incentives related to enrolling me in the healthcare plan. I acknowledge that no such claims or misleading promises have been made to me during the enrollment process.

Certification of Information Review and Acknowledgment

I, , REVIEWED AND CONFIRMED THAT MY APPLICATION INFORMATION IS CORRECT AND ACCURATE.

Applicant's Name:
Name of Agency of Record: Lapeira & Associates LLC
Agency Phone: +1 (855) 963 6900