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Your permission to help.

Federal rules say an agent needs your written permission before working on your Marketplace application. Here it is, filled in from your answers.

Who you are giving permission to

Name of primary writing agent
Edward Gudas
Agent national producer number
16974880
Phone number
1-847-754-4628
Email address
Edward@gradepointinsurance.com
Name of agency
Gradepoint Insurance Group, LLC
Agency national producer number
21297322
Owner of agency
Edward Gudas
Phone number
1-847-754-4628
Email address
Edward@gradepointinsurance.com

What you are agreeing to

English. This is the version you are signing.

The CMS Model Consent for Agents and Brokers is a federal form. Its English text is the text that has legal effect, on this page and on the Spanish page.

I, [First Name] [Last Name], give my permission to Edward Gudas to serve as the health insurance agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following:

  • Searching for an existing Marketplace application;
  • Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums;
  • Providing ongoing account maintenance and enrollment assistance, as necessary; or
  • Responding to inquiries from the Marketplace regarding my Marketplace application.

I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.

I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by e-mailing Edward at edward@gradepointinsurance.com.

Show the Spanish translation
Spanish. Courtesy translation, not the legal text.

Provided so a Spanish speaker can read what the English says. It is not what you are signing and it has no legal effect.

Yo, [Nombre] [Apellido], doy mi permiso a Edward Gudas para actuar como agente o corredor de seguros de salud para mí y para todo mi hogar, si corresponde, con el fin de inscribirme en un Plan de Salud Calificado ofrecido en el Mercado Facilitado por el Gobierno Federal. Al aceptar este acuerdo, autorizo al Agente mencionado a ver y usar la información confidencial que yo entregue por escrito, de forma electrónica o por teléfono, únicamente para uno o más de los siguientes fines:

  • Buscar una solicitud existente en el Mercado de Salud;
  • Completar una solicitud de elegibilidad e inscripción en un Plan de Salud Calificado del Mercado o en otros programas gubernamentales de ayuda con el costo del seguro, como Medicaid y CHIP, o los créditos fiscales anticipados que ayudan a pagar las primas del Mercado;
  • Dar mantenimiento continuo a mi cuenta y ayuda con la inscripción, según sea necesario; o
  • Responder a las consultas del Mercado sobre mi solicitud.

Entiendo que el Agente no usará ni compartirá mi información de identificación personal (PII, por sus siglas en inglés) para ningún fin distinto de los mencionados arriba. El Agente se asegurará de mantener mi PII privada y segura al recopilarla, guardarla y usarla para los fines indicados.

Confirmo que la información que entrego para mi solicitud de elegibilidad e inscripción en el Mercado será verdadera según mi leal saber y entender. Entiendo que no tengo que compartir con mi Agente información personal adicional sobre mí ni sobre mi salud más allá de lo que exige la solicitud para efectos de elegibilidad e inscripción. Entiendo que mi consentimiento sigue vigente hasta que yo lo revoque, y que puedo revocarlo o modificarlo en cualquier momento escribiendo a Edward a edward@gradepointinsurance.com.

cms-model-consent-2026.1

How we reach you

If a family member, friend or power of attorney is helping you with this, put their name here.

What is recorded with your signature

A signature is only worth something if there is a record of what was signed and by whom. Here is the whole list. There is nothing else, and nothing hidden.

Recorded by our server

Collected by Cloudflare when your browser makes the request. You cannot change these, and neither can we.

  • The time the request arrived, in UTC
  • Your IP address
  • The country, region, city and postal code Cloudflare associates with that address
  • Your network operator and its ASN
  • Which Cloudflare data centre answered
  • The HTTP protocol and TLS version used
  • The time zone Cloudflare associates with that address
  • The full user agent string your browser sends
  • The languages your browser asks for
  • The page you came from
  • A reference number generated for this record

Reported by this page

Read in your browser and sent up with the form. Labelled as client reported, because a browser can be told to say anything.

  • Your clock, in UTC and in local time
  • Your time zone and its offset from UTC
  • The languages your browser is set to
  • Your platform and browser, as your browser describes them
  • Your screen size and colour depth
  • The size of this window
  • Your device pixel ratio
  • Your reduced motion, colour scheme and pointer settings
  • The page you landed on, this page, and the page that sent you here
  • How long you spent on each step, and in total
  • The version and SHA-256 hash of each consent text you were shown, and in which language

Why the hash matters

The hash is a fingerprint of the exact words on this page. If a single character of the consent changed, the fingerprint changes. It is what proves later which text you agreed to, and the record says which language version you were reading when you agreed to it.

Your signature itself

The picture of your signature stays in this browser. What goes to the server is its SHA-256 hash, its size and how much ink is on it, which is enough to bind this record to the mark you made. The picture is put back into the copy you download.

What is deliberately not collected No canvas or WebGL fingerprinting, no font enumeration, no audio fingerprinting, and no other covert device signal. An audit trail records something you chose to do. It is not a tracking apparatus, and building one here would undermine the consent this form exists to collect.

Your agreement

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Date signed:

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Nothing here is sent anywhere. Demonstration. No application is transmitted to CMS or any carrier.
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