Please enable JavaScript in your browser to complete this form.

Contact Us to get a health insurance quote

Purpose for Obtaining Consent

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.

The contents of this document do not have the force and effect of law and are not meant to bind the you in any way. It is simply to document your consumer consent allowing Mark Schlange to access and or update your Marketplace information.

Declaration of Consent for Marketplace Nebraska

I give my permission to Mark Schlange, to serve as the health insurance agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following:

  1. Searching for an existing Marketplace application
  2. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums
  3. Providing ongoing account maintenance and enrollment assistance, as necessary; or
  4. Responding to inquiries from the Marketplace regarding my Marketplace application.

I understand that the Agent will not use or share my personally identifiable information (PII) 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 confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by emailing Marketplace Nebraska at: [email protected].


Agent of Consent Information

Name of Primary Writing Agent:
Mark Schlange
Agent National Producer Number:
Phone Number:
Email Address:
[email protected]

Name of Agency:
Marketplace Nebraska
Agency National Producer Number:
Owner of Agency:
Mark Schlange
Phone Number:
Email Address:
[email protected]

Primary Household Contact Signature

Contact Email