CONSENT FORM

The Centers for Medicare and Medicaid Services (CMS) requires health insurance agents and brokers to obtain a customer’s consent prior to helping them apply for a subsidy and/or enroll in a Marketplace Qualified Health Plan (QHP).

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By filling out this form you give Colonial Tax Insurance & Medicare and its Representatives permission to:

* 2) Check the status of your coverage and make updates throughout the year at your request; and

* 3) Have your permission indefinitely or until you change it in writing.

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Colonial Tax Insurance-Medicare

1525 East Colonial Drive, Orlando, Florida 32803, United States

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