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By signing, I grant permission to act on my behalf and that of my entire household in matters related to enrollment in a Qualified Health Plan via the Federally Facilitated Marketplace. This authorization extends to any authorized representative or power of attorney acting on my behalf. I acknowledge that individuals currently receiving VA, Medicare, or Tricare benefits are not eligible for these services. The agents empowered by this agreement are Michael Walker and Balance Benefits Group agents, who are authorized to locate existing Marketplace applications, complete applications for eligibility, provide maintenance, and handle inquiries about my application. Before submitting my application to the Marketplace, I confirm that I have reviewed and attested to the accuracy of my eligibility application information. Regarding premium tax credits, l understand that l'm not eligible for such credits if I qualify for other health coverage like Medicaid, CHIP, or a job-based health plan. Should I become eligible for other qualifying health coverage, I commit to informing the Marketplace to adjust or end my premium tax credit. I am aware that failure to do so may result in a requirement to repay the credit, and that the receipt of a premium tax credit obligates me to file a federal income tax return for the applicable tax year. I also consent to receiving SMS, phone calls, and emails from Balance Benefits Group for further guidance and support. I understand my personally identifiable information will be solely used for these purposes. I attest to the accuracy of the details I provide and can revoke or modify this consent by contacting [email protected]. This agreement aligns with CMS regulations concerning consent documentation and consumer PII protection.

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