Form Contact – lionyx insurance

CONSENT FOR BROKER ASSISTANCE

AS REQUIRED UNDER THE 2023 CMS-9899-F AMENDMENT OF 45 CFR § 155.220

This consent form outlines your rights. Please read it carefully.

As a licensed Health Insurance Broker, Shamsieh Jahangiri of Lionyx Insurance has completed the annual Affordable Care Act certification by the Marketplace in your state. With this yearly training, and an individual or family’s formal consent, brokers are authorized to search for and assist households with their Marketplace account. The purpose of this form is to receive your informed written consent.

Terms of Consent

I give my permission to Lionyx Insurance, and/or their staff to provide the following services on behalf of myself, and my entire household if applicable.

Search for an existing Marketplace application;
Completing an application for eligibility and enrollment in a marketplace Qualified Health Plan or government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace Premiums or enrollment in off-exchange insurance products as applicable.
Providing ongoing account maintenance and enrollment assistance, as necessary; or
Responding to inquiries from the Marketplace regarding my Marketplace application.

I understand that Lionyx Insurance and/or their staff will not share my personally identifiable information (PII) and they will ensure that my PII is kept private and safe when collecting, storing, and using my information 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 my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time. I understand that requests must be made in writing, either by sending the request via certified mail to the address below or via email to info@lionyxllc.com.

Agency Contact Information

Lionyx Insurance | (281) 994-4236 | 22503 Katy Fwy Ste 43 Houston, TX 77450

Agent Point of Contact

My Broker | Shamsieh Jahangiri | info@lionyxllc.com | NPN: 18708768

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zip code

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You must agree to the following terms before you click submit *

I understand that by clicking submit below, I am attesting that the information provided is true and correct to the best of my abilities.

I understand that by clicking submit below, that I am authorizing this broker, Shamsieh Jahangiri NPN: 18708768, to be listed as the broker of record on my Marketplace account.

I understand that by giving this authorization, I consent to have the broker, Shamsieh Jahangiri NPN: 18708768, access my data within my states designated exchange.

I understand that I may revoke access by request at ANY time directly with the Exchange without cause OR by emailing my request to my broker.

Signature

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