Consent to Serve as an Authorized Representative in Order to Facilitate Enrollment for Applicant

• I, the applicant, hereby appoint to serve as an Authorized Representative to facilitate my application on behalf of myself and anyone listed on this application.
• I, the applicant, understand that my Authorized Representative may discuss my application with Nevada Health Link, see and disclose necessary information to Nevada Health Link, and act on my behalf on matters related to my application,including receiving information about my application and signing my application on my behalf.
• I, the applicant, understand that this information will be used for eligibility determination for enrollment in Nevada Health Link health and/or dental plans, Advance Premium Tax Credits (APTC), and/or other public health insurance programs such as Nevada Medicaid or Nevada Check-up.
• I, the applicant, understand that individuals on this form have the right to review the Nevada Health Link Privacy Notice before signing the form and to request a copy at any time.
• I, the applicant, consent to the use of my Social Security Number by my Authorized Representative for the purpose of identification.
• I, the applicant, understand that I may revoke this authorization by notifying my Authorized Representative and Nevada Health Link in writing. If I revoke the authorization, it will not affect any actions already taken by my Authorized Representative.
• I, the applicant, understand that I may request a copy of this completed authorization form.

For purposes of facilitating Nevada Health Link enrollment, unless revoked, this authorization permits my Authorized Representative to facilitate eligibility determination and enrollment on behalf of myself, and anyone listed on this application. Authorization can be revoked at any time by the applicant, or by the Authorized Representative if they no longer are acting or are no longer authorized to act in such capacity. (45 CFR 155.227(d))

• I understand that the information contained in my Nevada Health Link application is used to determine eligibility for coverage and, when applicable, financial assistance such as Advance Premium Tax Credits (APTC) and cost-sharing reductions.
• I certify that the information I have provided to Senior Insurance Agency for my application is true, complete, and accurate to the best of my knowledge. I understand that Senior Insurance Agency may rely upon information I provide when assisting me with my application, enrollment, renewal, or requested changes.
• If I request a change to my application after signing this form, I understand that I am responsible for reviewing the information I provide and confirming that the requested change is accurate before Senior Insurance Agency submits the change to Nevada Health Link. My confirmation may be provided in person or through a documented electronic communication, including email.
• After an application or requested change is submitted, I agree to review any application information, eligibility determination, or other notice made available to me by Nevada Health Link and to promptly notify Senior Insurance Agency or Nevada Health Link if I identify an error or omission.
• I understand that I am responsible for providing accurate information and for reporting changes that may affect my eligibility, enrollment, or financial assistance.

• The Silver State Health Insurance Exchange (Exchange) is responsible for operating and managing Nevada Health Link, Nevada’s health insurance marketplace where consumers can shop and enroll in health or dental coverage. (NRS 695I.210)
• An applicant can appoint an Authorized Representative to act on his or her behalf in applying for Nevada Health Link eligibility determination or redetermination.
• The Authorized Representative may act on behalf of the applicant in all matters related to the Exchange/Nevada Health Link. (45 CFR 155.227(a))

• Maintain, or be legally bound to maintain, the confidentiality of any information regarding the applicant provided by the Exchange. (45 CFR 155.227(a)(3))
• Be responsible for fulfilling all responsibilities encompassed within the scope of the authorized representation to the same extent as the applicant he or she represents. (45 CFR 155.227(a)(4))
• Abide by federal and state laws and regulations pertaining to the Exchange.

I, the applicant, hereby appoint and give permission to the Authorized Representative identified below to assist with my application and enrollment in a Qualified Health Plan (QHP), Qualified Dental Plan (QDP), Stand-Alone Dental Plan (SADP), and/or Nevada Medicaid plan offered through Nevada Health Link. By completing and signing this form, I agree to allow my Authorized Representative to collect required information and pursue enrollment on my behalf, in accordance with the Nevada Health Link Privacy Policy and applicable state and federal laws.