WA HealthPlanFinder Consent Form

This consent gives permission to The Quintana Group to serve as the health insurance agent for myself, and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Washington Health Benefit Exchange (WAHBE).

By consenting to this agreement, I authorize The Quintana Group to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following:

1. Searching for an existing WAHBE application;
2. Completing an application for eligibility and enrollment in a Qualified Health Plan or other government insurance affordability programs, such as Washington Apple Health or Advance Premium Tax Credits to pay for WAHBE premiums;
3. Providing ongoing account maintenance and enrollment assistance, as necessary; or
4. Responding to inquiries from the WAHBE regarding my WAHBE application.

I understand that The Quintana Group will not use or share my personally identifiable information (PII) for any purposes other than those listed above.

The Quintana Group 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 I do not have to share additional personal information about myself or my health with The Quintana Group beyond what is required on the application for eligibility and enrollment purposes.

If I am applying for financial assistance, I'm signing the application under penalty of perjury. I know I may be subject to penalties under federal law if I intentionally provide false information.

I understand that if at the end of the year I’ve received more premium tax credit in advance than I qualify for based on my final income, I will be required to pay back the excess when I file my federal tax return. If I’ve received less premium tax credit than I qualify for I’ll get the difference back when I file my federal tax return.

Additionally, before enrolling in coverage I will review my Washington HealthPlanFinder eligibility and enrollment application information. I confirm that the information I have provided will be accurate and true to the best of my knowledge including my contact information and my income reported.