CONSENT OF REP
RESENTATION
With the guidance of licensed insuance brok
ers and certified behavioral health profess
ionals, Hopedealers Worldwide assists those
impacted by the disease of addiction and t
heir family and loved ones, whether in cris
is or in recovery, obtain affordable health
insurance in order to obtain preventative
and necessary medical treatment and appropr
iate care.
I voluntarily give consent of representatio
n to Hopedealers Worldwide (licensed broker
s - Nadine Psareas, Amber Robinson, Julia E
mory, Jordan Porter, Peter Psareas, Misty B
aylin, or Delroza Hughes) to guide me with
the health insurance process through the AC
A healthcare exchange/marketplace.
I understand all information submitted to H
opedealers Worldwide is protected under the
Federal regulations governing Confidential
ity and Drug Abuse Patient Records, 42 C.F.
R. Part 2, and the Health Insurance Portabi
lity and Accountability Act of 1996 (“HIPAA
”), 45 C.F.R. pts 160 & 164, and cannot be
disclosed without written consent unless ot
herwise provided for by the regulations. I
also understand that I may revoke this cons
ent at any time, in writing, except to the
extent that action has been taken in relian
ce on it.
I understand that by receiving insurance thr
ough the ACA healthcare exchange/marketplace
, I am using tax credits to offset the cost
of the chosen health insurance plan. Should
I have tax-related questions I will consult
with my tax professional and I will not hold
Hopedealers Worldwide liable in any way. Ho
pedealers Worldwide does offer a specialized
tax professional to our clients at a very r
educed rate.
I understand that Hopedealers Worldwide is
a 501c3 non-profit organization that provid
es Integrative Behavioral Health Counseling
and Coaching among a variety of other supp
ort services for those in the community and
no person benefits financially or is compe
nsated from this service. Any commissions g
enerated are given to the 501c3 non profit
to serve the community. Helping and guiding
people with ACA marketplace insurance is a
100% community outreach.
I give my permission to Hopedealers Worldwi
de (Nadine Psareas, Amber Robinson, Julia E
mory, Jordan Porter, Peter Psareas, Misty B
aylin, or Delroza Hughes - licensed brokers
) to serve as the health insurance agent or
broker for myself and my entire household,
if applicable, for purposes of enrollment
in a QUALIFED health plan offered on the Fe
derally Facilitated Marketplace.
In the event I am not able to contact Hope
dealers Worldwide Agency, or if the agency
is unable to contact me, I risk losing my
policy as Hopedealers Worldwide MUST rece
ive consent each and every time an applica
tion is touched for viewing/updating/enrol
lment/renewal, etc.
By consenting to this agreement, I authoriz
e the above mentioned agency and agents to
view and use the confidential information p
rovided by me in this electronic form or by
phone only for one or more of the followin
g:
Searching for an exis
ting marketplace appl
ication
Completing an application for eligibilit
y and enrollment in a marketplace qualif
ied healthplan or other government insur
ance affordability programs, such as Med
icaid and CHIP or advanced tax credits t
o help pay for marketplace premiums
Providing ongoing account maintena
nce and enrollment assistance, as
necessary
Responding to inquiries from t
he marketplace regarding my ap
plication
I understand that the agency/agents will no
t use or share my personally indentifiable
information (PII) for any purpose other tha
n those listed above. The agent will insure
that my PII is kept private and safe when
collecting, storing, and using my PII for t
he stated purposes above.
I confirm that the information I provide
for the entry on my marketplace eligibi
lity and enrollment application will be
true to the best of my knowledge.
I confirm that I have reviewed my compl
eted application and that all informati
on is accurate.
I understand that I do not have to share add
itional personal information about myself or
my health with my agent beyond what is requ
ired on the application for eligibility and
enrollment purposes. I understand that my co
nsent remains in effect until I revoke it, a
nd I may revoke or modify my consent at any
time by contacting my agency/agent or revoki
ng it through my health sherpa dashboard.
HOPEDEALERS WORLDWIDE N
PN#20651087
Writing Agents:
PRINCIPAL AGENT: NADINE
PSAREAS - NPN#2036170
AGENT: AMBER ROBINSON-
NPN#20822293
AGENT: JULIA EMORY - NP
N#20800372
AGENT: JORDAN PORTER -
NPN#20886930
AGENT: PETER PSAREAS -
NPN#21086452
AGENT: DELROZA HUGH
ES: NPN# 21105290
AGENT: MISTY BAYLIN
- NPN#21231040
hopedealersworl
dwide@gmail.com
770.224.6825 OR
470.288.3201
