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Congratulations On Your New Health Coverage

Complete this form to protect your health insurance account, ensure that no changes are made to your coverage by previous agents, and authorize Quality Affordable Care to contact you in the future.

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Protect Your Account

Why this is important

By submitting this form, you ensure that only Quality Affordable Care agents can make changes to your health insurance account and revoke any previous agent authorizations. This helps prevent confusion and ensures that you receive the coverage and care that you expect.


Please review the following terms:

I give my permission to Quality Affordable Care to serve as the health insurance agent or broker for myself and my entire household, if applicable.

As such, I revoke any prior authorization given to any other agency or affiliated agents to access my health insurance account(s) through the Federally-facilitated Exchange, State-based Exchange, or EDE Partner Site. This includes permission to search, claim, edit, submit, cancel or enroll me in any health insurance coverage.

I request that any other agencies or affiliated agents delete all my personal identifiable information (PII) and that they cease accessing my health insurance information.