My contact information is:

I understand that I’m not eligible for a premium tax credit if I'm found eligible for other qualifying health coverage, like Medicaid, Children’s Health Insurance Program (CHIP), or a job-based health plan. I also understand that if I become eligible for other qualifying health coverage, I must contact FH Insurance Services and Covered California to end my coverage and premium tax credit If I don’t, the person who files taxes in my household may need to pay back my premium tax credit. I understand that because the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents:

1. I must file a FEDERAL income tax return for the 2026 tax year.

2. If I'm married at the end of 2026, I must file a joint income tax return with my spouse.

3. I must report any income changes throughout the year to prevent any issues with taxes.

I also expect that:

1. No one else will be able to claim me as a dependent on their 2026 Federal income tax return.

2. I’ll claim a personal exemption deduction on my 2026 Federal income tax return for any individual listed on this application as my dependent who is enrolled in coverage through Covered Ca, and whose premium for coverage is paid in whole or in part by advance payments of the premium tax credit. 

If any of the above changes:

1. I understand that it may impact my ability to get the premium tax credit. I also understand that when I file my 2026 Federal Income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I understand that if the income on my tax return is lower than the amount of income on my application, I may become eligible to get additional premium tax credit amount. On the other hand, if the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax.

By signing below, I give permission to FH Insurance Services to:

• Search for an existing Covered California application

• Complete enrollment

• Provide ongoing account maintenance and enrollment assistance, as necessary; or

• Respond to inquiries from the Covered California regarding my application.

This permission is granted for me, my spouse or any other household member listed on the application in the plan that we have listed.

I understand that the Agent will not use or share my personally identifiable information for any purposes other than those listed above. The Agent 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 my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by sending a request to revoke consent to Felipe@fhinsuranceservices.com that must be dated and signed.

Legal Disclosure: The contents of this document do have the force and effect of law and are not meant to bind the public in any way unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law. This model consent form will not supersede any State Agent of Record, Broker of Record, or other form required by a QHP issuer for purposes of making commission payments to the proper agent or broker for assisting a particular consumer. 

Purpose Statement: Registered agents and brokers assisting consumers apply for and enroll in Marketplace coverage must document consumer consent prior to accessing or updating their Marketplace information. CMS does not prescribe the manner in which agents and brokers must document consent. Instead, there are different formats that may be acceptable for agents and brokers to use to document consumer consent, such as via a recorded phone call, text message, email, electronic document with digital signatures, physical document with wet signatures, etc. This model consent form serves as an example for how agents and brokers may document consent via a physical document with wet signatures.