WA HealthPlanFinder Consent Form

We must keep a record of providing this notice and receiving consent from you to assist you in applying for and enrolling in coverage in the Washington HealthPlanFinder Health Benefit Exchange (WAHBE).

This consent gives permission to The Quintana Group to serve as the health insurance agent for yourself, and your entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the WAHBE.

By consenting to this agreement, you authorize The Quintana Group to view and use the confidential information provided by you 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 your WAHBE application.

You understand that The Quintana Group will not use or share your personally identifiable information (PII) for any purposes other than those listed above.  The Quintana Group will ensure that your PII is kept private and safe when collecting, storing and using your PII for the stated purposes above.

You understand that your consent remains in effect until you revoke it, and you may revoke or modify your consent at any time by contacting The Quintana Group at 503-699-7770, or www.thequintanagroup.com.  Or you can contact the Washington HealthPlanFinder at 855-923-4633.

Please complete the form to the right.

Review The Quintana Group Privacy Practices.

 


The Quintana Group Writing Agents:

Donna D. Quintana, RHU
National Producer Number:  3461267
Phone Number:  503-699-7770
Email Address:  donna@thequintanagroup.com

Shane P. Quintana, LUTCF
National Producer Number:  690411
Phone Number:  503-699-7770
Email Address:  shane@thequintanagroup.com

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.

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The Quintana Group is not connected with or endorsed by the U.S. Government or with the federal Medicare program. We do not offer every plan available in your area. Currently, we represent 6 organizations in 2 states which offer 46 plans (plan availability depends on the zip code in which you reside). Please contact Medicare.gov, 1-800-Medicare or your local State Health Insurance Program (SHIP) to get information on all of your options.

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