Agent and Broker Privacy Act Statement

We are authorized to collect the information on this form and any supporting documentation, including your name, contact information and National Producer Number (NPN), under the Patient Protection and Affordable Care Act (Public Law No. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law No. 111-152), its implementing regulations at 45 CFR 155.220 and the Agent or Broker Agreement executed between you and CMS that authorizes you to assist consumers, applicants, qualified individuals, and enrollees through the Federally-facilitated Exchange or State Partnership Exchange in the Individual Market in the state in which you are licensed and have registered with CMS.

We need the information about you to register and certify you to assist consumers, applicants, qualified individuals, and enrollees who are applying for advance payments of the premium tax credit (APTCs) and cost-sharing reductions (CSRs) for qualified health plans (QHPs) and/or in completing enrollment in a QHP and to provide customer service and assistance understanding consumers options with respect to health insurance coverage. As part of that process, we will verify the information you provide on the form and communicate with you to provide you with your certification credentials. We will also use the information you provide as part of the ongoing operation and monitoring of the Marketplace, including activities such as verifying your continued eligibility for participation as an agent or broker to assist consumers, applicants, qualified individuals, and enrollees, performing oversight and quality control activities, combatting fraud, and responding to any concerns about the security or confidentiality of the information that you provide about yourself or personally identifiable information that as an agent or broker you collect, create, use or disclose in the course of assisting consumers, applicants, qualified individuals, and enrollees.

Providing the requested information is voluntary. However, failing to provide it may delay or prevent your ability to register and become certified to assist consumers, applicants, qualified individuals, and enrollees, apply for APTCs and CSRs for QHPs and/or in completing enrollment in a QHP and to provide customer service. If you don’t provide correct information on this form or knowingly and willfully provide false or fraudulent information, you may be subject to a penalty and other law enforcement action.

In order to verify and process registration forms, determine your eligibility to participate, and operate the Marketplace, we will need to share selected information that we receive from you on the registration form outside of CMS, including to:

This statement provides the notice required by the Privacy Act of 1974 (5 U.S.C. § 552a(e)(4)). You can learn more about how we handle your information at: https://www.healthcare.gov/how-we-use-your-data.