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Agency Name: Jaguar Health Inc & Associates
Agent Name: Jonathan Dar
NPN: 21040312
Email: jonathandarhealth@gmail.com
APPLICANT ACKNOWLEDGMENTS & CONSENTS
Personal and Income Information Accuracy
I confirm that all personal and income-related information I have provided is accurate and truthful to the best of my knowledge. This information will be used to determine my eligibility for health insurance and any applicable subsidies.
Appointment of Agent of Record
I appoint the above-listed agent as my official agent of record for all matters related to health insurance, including but not limited to enrollment assistance, policy modifications, and claims support. I understand that this designation can be revoked or changed at any time by providing written notice via email, postal mail, or in-person communication.
Acknowledgment of Health Sherpa NPN Use
I acknowledge that my enrollment may be processed using a Health Sherpa National Producer Number (NPN). The Health Sherpa NPN that may be used is: Jonathan Dar (NPN: 21040312) I understand that my selected agent will maintain access to and provide ongoing service for my enrollment.
Scope of Appointment
I acknowledge that this appointment is valid for 12 months from the date of signing and will automatically renew annually unless I choose to revoke it.
Special Enrollment Period (SEP) Acknowledgment
I understand that certain life events may qualify me for a Special Enrollment Period (SEP) outside the annual Open Enrollment Period. My agent may assist me in determining eligibility and completing the enrollment process if I qualify.
HIPAA Authorization
I authorize my agent to access and share my protected health information (PHI) as needed for insurance enrollment, policy servicing, and claims support. This may include, but is not limited to:
Application details
Policy status and changes
Claims data
Eligibility verification
This authorization complies with HIPAA regulations and can be revoked at any time by providing written notice via email, postal mail, or in person.
Communication Consent (TCPA Compliance)
I consent to receive communications from my agent regarding health insurance, benefits, and related matters via: Phone calls Emails SMS/text messages
Automated or prerecorded calls
By submitting this form, I provide express written consent under the Telephone Consumer Protection Act (TCPA) to receive such communications. I understand that message and data rates may apply.
AI Systems Communication Consent
I agree to receive AI-generated or automated communications related to health insurance, including updates and reminders, via SMS, email, or voice calls from my agent. I may opt out of these communications at any time.
Opt-Out Instructions
I may opt out of communications at any time by: Replying STOP to SMS messages Emailing my agent at jonathandarhealth@gmail.com Calling or sending a written request to my agent
Purpose of Communications
Communications from my agent may include:
Health insurance enrollment updates
Policy changes and renewals
Claims assistance and follow-ups
CMS Marketplace compliance notifications
Policy Confirmation
Upon successful enrollment I will receive confirmation of my health insurance policy from the insurance provider. This will include: My policy details (coverage start date, benefits, premium) My policy number Customer service contact info It is my responsibility to review this and report any errors to my agent.
No Guarantees
My agent will try to find the best options based on my eligibility, but no benefits, savings, or coverage are guaranteed.
Data Protection & Privacy
My information will be handled securely and in compliance with all applicable data protection laws.
Transparency & No Misleading Information
I confirm I have not been misled and that everything has been explained clearly and accurately.
CMS Requirements Acknowledgment
I understand CMS requires consent documentation before applying for coverage, and I have reviewed my application for accuracy.
Right to Modify or Revoke Consent
I can modify or revoke my consent at any time via written notice.
Documentation & Record Retention
I consent to enrollment and understand that my application records will be retained for at least 10 years.
Automatic Plan Re-Enrollment & Upgrade Authorization
I request to be re-enrolled in my current plan automatically at renewal and authorize my agent to move me to a better plan if eligible.
