When you schedule an appointment with us we ask that you review and sign this document. If you have any questions or concerns about how or why we use your information, or would like to alter this agreement please let us know.
Revised September 8, 2023
PRIVACY NOTICE AND AUTHORIZATION FORM
This notice explains how Josh and/or Mary Viles may collect, use, and share your personal information. Please read this notice carefully.
Josh and/or Mary Viles must collect certain information about you, called Personally Identifiable Information (“PII”), in order to help you complete your application for health insurance. We only use PII to the extent necessary to assist you with the application and enrollment process.
Some examples of PII required for health coverage applications and enrollment include your name, address, zip code and county of residence, birthdate, telephone, social security number, household income, number of household members, marital status, race/ethnicity, Healthcare.gov username and password, CommonHelp Application username and password, and/or any information necessary to assist you.
Why did I receive this notice?
Josh and/or Mary Viles are required to give you this notice by applicable State and Federal law. We respect your personal information and want you to fully understand how we may use and share your information. Your decision to provide your personal information is voluntary. We are required to obtain your written authorization prior to collecting, creating, disclosing, accessing, maintaining, storing or using your PII. Neither you, nor your legal or authorized representative, are required to provide more information than you choose to provide. You can revoke, limit, or otherwise change the consents you provide through this notice at any time.
How will you use my information?
Josh and/or Mary Viles will use only the information that we need to help you obtain health insurance through the Virginia Health Benefit Exchange, the Virginia Medicaid Program, and the FAMIS program. [Name of CDO] is authorized by law to: provide you information about the full range of options available to you with respect to qualified health plans, qualified dental plans, the State Medicaid Program, and FAMIS; assist you in applying for coverage; and help to facilitate your enrollment.
Will my information be shared with anyone?
Josh and/or Mary Viles may only share your personal information as described in this notice. We may share your information with certain Federal or State agencies, the health insurance issuer that you select or subcontractors that help us to provide services to you. We do not share your personal information with anyone else without your consent.
Will you keep my information safe?
Yes. Josh and/or Mary Viles are required by law to keep your information safe. The Virginia Health Benefit Exchange has developed privacy and security policies/practices that we must follow to make sure that we protect your information. For your protection, please do not send e-mails to us that contain your PII. We cannot guarantee the security of these e-mails before they reach us. Josh and/or Mary Viles are committed to protecting your personal privacy. Keeping information secure and using it in a responsible manner is a top priority.
Under what legal authority are you permitted to collect my PII?
Both Federal and State laws permit Josh and/or Mary Viles to collect PII for the reasons referenced above. State regulations include 14VAC7-10-10 et seq. of the Virginia Administrative Code. Federal laws and regulations include Section 1411(g) of the Patient Protection and Affordable Care Act (42 U.S.C. §18081(g) and 45 C.F.R. §155.260).
How will you inform me about changes to this Privacy Notice?
For any questions or concerns, please contact:
Mary Viles (804)241-0048 firstname.lastname@example.org
Josh Viles (757)635-3425 email@example.com
If you believe your Personally Identifiable Information has been or may have been compromised in any way and you would like to file a complaint with the Virginia Health Benefit Exchange, please go here: https://www.scc.virginia.gov/pages/File-an-Insurance-Complaint-(1).
By clicking this box you agree that you have read through the PRIVACY NOTICE AND AUTHORIZATION FORM and agree to give permission to Josh and/or Mary Viles to create, collect, disclose, access, maintain, store, and/or use my personal information in order to carry out the roles and responsibilities that are authorized by federal and state laws and regulation, unless I have limited that consent. You agree that we may access your Marketplace application on your behalf.
Please type your name below as your signature*
Printed Consumer’s Legal of Authorized Representative Name (if applicable)__