Privacy Notice Statement for Use of Private Health Information
I authorize Candy Hilliard (agent at American Family Protectors), as well as any other staff and contract workers affiliated with American Family Protectors, to create, collect, disclose, access, maintain, store, and use personally identifiable information from me and my family (if applying for insurance). Any private health information collected by American Family Protectors can be used for any or all of the following:
1.) Assisting with the application for a qualified health plan.
2.) Assisting with applications for the receipt of advanced premium tax credits or cost-sharing reductions.
3.) Facilitating the collection of standardized attestations acknowledging the receipt of the advanced premium tax credit or cost-share reduction determination if applicable.
4.) Assisting with the application for and determination of certificates of exemption.
5.) Assisting with filing appeals of eligibility determinations in connection with the Federal Facilitated Marketplace or healthcare.gov.
6.) Facilitating payment of initial premium amount to the qualified health plan provider.
7.) Facilitating your ability to dis-enroll from a qualified health plan.
If you choose to give American Family Protectors private health information, we may share this information with healthcare.gov and health insurance providers.
Sharing this information with us is on a voluntary basis. If you choose to not provide us with the private health information and/or not respond to certain questions, we will not be able to assist you with the listed services and will instead direct you to healthcare.gov. You can elect to discontinue this agreement by providing us a written letter via email to email@example.com or via traditional mail to 1000 Peachtree Industrial Blvd, Suite 6-454, Suwanee, GA, 30024.