By completing and signing this form, you are authorizing your assister to create an account for you on MNsure.org because you do not have access to computer and cannot meeting in-person with an assister. Creating an account is the first step to determine your eligibility for benefits and enrolling in health coverage. To create a new account, MNsure must collect enough information to verify your identity. Your assister will ask for this information from you to enter when he or she is creating the account. Your information is private and he or she must safeguard it. When your assister is creating your account, he or she must provide a privacy warning from MNsure about the information being requested and ask if you agree to the MNsure terms and conditions. By asking an assister to create an account for you, you agree to use the system for authorized purposes only, in compliance with state and federal law, and agree to the MNsure Terms and Conditions. A copy of the privacy warning and the terms and conditions are available at www.mnsure.org/resources/terms-conditions.jsp. Your assister cannot create your account if you do not agree.
By completing and signing this form, you are giving permission for your assister to enter your account and associate your account with your assister’s account. After your account is associated with your assister, he or she is authorized to act on your behalf and on behalf of any others on your application for the following actions:
• Access your data to provide customer service
• Enter information about you or your household into an application
• Submit an application for you
• Select a qualified health plan
• Select and apply advanced premium tax credit amount
You are also authorizing this assister to provide and view information on all the people on your application. MNsure applicants or assisters who provide and view information on behalf of applicant or household members, dependents, employees or others verify that they have the permission of the individual data subject, or are the legal guardian, or are otherwise authorized to access and submit the information, and must agree to safeguard it. Individuals who view or submit information on behalf of another individual also agree to only use the personally identifiable information for the purpose of completing the proper application or as otherwise allowed by state and federal law and to safeguard the data from unauthorized access, use, modification, destruction, theft, or disclosure. The information on an application is private data.
By signing below, you are allowing this assister to receive information about your application and act on matters related to this application, including signing your application on your behalf and enrolling in a qualified health plan on your behalf. You also acknowledge that you are still responsible for meeting all applicable deadlines for enrolling in coverage.
Please provide the following information about the assister you wish to authorize: