Client Consent Form

Utah Health Policy Project (UHPP)

2369 W. Orton Circle, Suite 20

West Valley City, UT 84119

801-850-0008 ext. 225

I, ______________________, give my permission or, ______________________, my authorized representative acting on my behalf (“authorized representative”) gives permission to UHPP and its Health Access Assisters, who are certified by UHPP and meet all the requirements of to collect, use, disclose, store, and/or maintain my personally identifiable information (PII) and/or the PII of my authorized representative, to perform the duties of assisting with health insurance enrollment. PII includes, but is not limited to, name, phone number, address, email address, demographic information, language preference, Marketplace application ID, insured status, and other social service needs status.

I understand that I may revoke this authorization at any time and will notify UHPP if I choose to revoke my authorization.

I understand that UHPP will have the following responsibilities and will perform the following functions:

• Inform me and/or my authorized representative about the full range of health insurance coverage options and insurance affordability programs (such as Medicaid or CHIP) for which I’m eligible;
• Provide me and/or my authorized representative with fair, accurate, and impartial information;
• Help me and/or my authorized representative apply for health insurance coverage or for insurance affordability programs;
• Help me and/or my authorized representative enroll in a health insurance plan or in an insurance affordability program, and
• Act in my best interest and not provide information or guidance influenced by compensation received for services rendered.
• I permit UHPP to create, collect, disclose, access, maintain, store, and/or use my PII for case management purposes and to follow-up with me or my authorized representative by phone, email, or in person by the end of the applicable coverage period to learn whether I would like help re-enrolling in health insurance coverage and/or insurance affordability programs.
• I authorize UHPP to utilize virtual and remote methods of conducting case management and application assistance in order to ensure my successful enrollment. This may include;
  • Electronic signature platform DocuSign use for completing consent forms, applications, verifications or other.
  • Screen sharing between myself and UHPP to assist in navigating applications, plan selection, or verification submission.
  • Application questions and completion via phone if other virtual methods are not possible for me.
  • Using a safe third-party website called HealthSherpa.com for the application process, plan quoting, document verification uploads and case managing assistance.
• UHPP will follow privacy and information security standards when creating, collecting, disclosing, accessing, maintaining, storing and or using my PII and/or the PII of my authorized representative.  PII will only be used for purposes of determining eligibility for enrollment, determining eligibility for other insurance affordability programs, or determining eligibility for exemptions from individual shared responsibility provisions. UHPP may only use or disclose such personally identifiable information to the extent such information is necessary. UHPP PII policy will be provided on request.
• If UHPP is unable to assist me and/or my authorized representative for any reason, they will refer me or my authorized representative to another person who can help me. I understand that UHPP may need to ask about and keep notes on any supports or services I might need in order to help me.
• UHPP will provide me with a copy of this form if I request it.
• UHPP will not discriminate against me based on my race, color, national origin, disability, age, sex, gender identity, or sexual orientation.
• If I have any concerns about the help UHPP provides to me, I should contact UHPP at 801-850-0008.