Consumer Consent Form for
Georgia Access Agents

I give permission to the above mentioned agent/agency to serve as the health insurance agent for myself and my entire household if applicable, for enrollment in a Qualified Health Plan offered on the Georgia State- based Exchange(Georgia Access). By consenting to this agreement, I authorize the above-mentioned agent/agency to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purpose of one or more of the following:

1. I give permission to access my information for the purpose of helping me complete an application for eligibility and enrollment in a Qualified Health Plan or other insurance affordability programs, such as Medicaid and PeachCare for Kids® (CHIP) or advance tax credits to help pay for insurance premiums.

   Clear

   Date:

   2026-06-09
   
   
   

2. I agree that I have been informed and agree with all the disclaimers included in my exchange application.

   Clear

   Date:

   2026-06-09
   
   
   

3. I understand the plan(s) I am being enrolled in and agree that I wish to be enrolled in that plan; I understand that I may cancel the delegation at any time either within the Georgia Access portal, a certified partner portal, or by calling the Georgia Access contact center at 1-888 - 687 - 1503.

   Clear

   Date:

   2026-06-09
   
   
   
4. I give the agent only   
   OR agent and any member of their agency

      permission to assist me in maintaining my information and changing my plans in the future without requiring consent. I understand that I am not obligated to provide this consent, but if I do not, I will need to document a new consent every time I require future assistance from my agent.

   Clear

   Date:

   2026-06-09