Consent Form

I, hereby give my consent on this date, for LIOR Agency, LLC to carry out functions related to my enrollment, Periodic eligibility updates (clients will be notified of all eligibility updates) plan selections, and ongoing account and enrollment maintenance. I agree to inform LIOR Agency, LLC of any changes regarding my phone number, email, income, job, household size, address or contact with any other insurance company offers. I explicitly authorize LIOR Agency, LLC to automatically renew my plan for the upcoming year (2026-27) or select a similar, most suitable plan available (client will be notified of any changes). By consenting to this agreement, I authorize the above-mentioned Agency/Agents to view and use the confidential information provided by me in writing, electronically, or by phone only for only for the purpose of 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 Marketplace application.

·        Renew my plan or most suitable plan (client will be notified of any changes).  for the upcoming Enrollment Year.

I understand that the LIOR Agency, LLC/Agents, will not use or share my personally identifiable information (PII) for any purposes other than those listed above. LIOR Agency, LLC will ensure that my PII is protected when creating, collecting, disclosing, accessing, maintaining, storing, and using my PII for the stated purposes above.

I understand that I do not have to share additional PII or protected health information (PHI) with LIOR Agency, LLC/Agents, beyond what is required on the Marketplace application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it by calling LIOR Agency, LLC or providing a written notice to LIOR Agency, LLC at 17350 State Hwy 249, Ste 220, Houston, TX 77064-1132, Toll Free 1 (844)368-9622 or by calling the Market Place directly.

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