Form CMS-10472 Model Authorization Form (Navigators)

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Updated 11/2014-DRAFT
Appendix D: DRAFT Model Authorization Form for Navigators
in a Federally Facilitated Marketplace or State Partnership Marketplace (Marketplace)
Navigator Organization Name: __________________________________________________
Navigator Organization Address: _________________________________________________
Navigator Organization Phone Number and E-mail Address:
______________________________________________________________________________
Individual Navigator Name or Staff/Volunteer Name and Certification Number:
_________________________________________________________________________________
I.

Acknowledgement of Roles and Responsibilities of Navigators (see Attachment A)

I have been informed about and understand the Navigator roles and responsibilities set forth on Attachment A
and have been given the opportunity to discuss them with [Name]. 1
II.

Definitions and Explanations of Terms Used in This Form

In this authorization form:
 The words “I,” “me,” or “my” include my authorized representative if I have one.
 Personally identifiable information is called “PII.” Examples of my PII include, but are not limited to my
name, phone number, email address, home address, immigration status, income, and household size
information.
 Health plans available through the Marketplace are called Qualified Health Plans or “QHPs.”
 Other programs called “insurance affordability programs” are also available through the Marketplace.
These programs can help me or my family pay for health coverage, and include public programs, such
as Medicaid or the Children’s Health Insurance Program (CHIP), premium tax credits, cost-sharing
reductions, and, if one is available in my state, the Basic Health Program.
III.

Authorizations
a. General Consent

I, ______________________, give my permission to [Name], including the individual Navigators who are a part
of this Navigator organization, to create, collect, disclose, access, maintain, store, and/or use my PII in order to
carry out the following duties of a Navigator, unless I have limited that consent as set forth in this document. I
1

NOTE TO NAVIGATOR ORGANIZATION AND INDIVIDUAL NAVIGATOR: Each time [Name] appears in this Authorization
Form, the Name of the Navigator Organization, at a minimum, should be inserted. Individual Navigator name(s) may, but
are not required, to be inserted.

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understand that [Name] might need to create, collect, disclose, access, maintain, store, and/or use some of my
PII in order to provide this assistance.
1. Telling me about the full range of QHP options and insurance affordability programs for which I may be
eligible, which includes: providing me with fair, accurate, and impartial information that assists me with
submitting a Marketplace eligibility application; clarifying the distinctions among health coverage options,
including QHPs; and helping me make informed decisions during the health coverage selection process.
The information must be provided in a way that that meets my cultural and language needs. I understand
that [Names] might need to ask about and keep notes on my health coverage needs and language
preferences in order to help me.
2. Ensuring that tools and help provided are accessible and usable for me if I have disabilities. I understand
that [Name] might need to ask about and keep notes on any supports and services I need in order to help
me.
3. Helping me to select a QHP.
4. Helping me with grievances, complaints, or questions about my health plan, coverage, or a determination
under such a plan or coverage, by providing me with referrals to any applicable office of health insurance
consumer assistance or health insurance ombudsman, or any other appropriate state agency or agencies. I
understand that [Name] might need to disclose my PII to those referral sources in order to help me.
5. Providing me with this form and storing a signed copy of it.
b. Specific Consents
I also permit [Name] to create, collect, disclose, access, maintain, store, and/or use my PII, for the following
purpose(s):


To follow-up with me by the end of the applicable coverage year to learn whether I would like help
with re-enrolling in Marketplace coverage and/or insurance affordability programs. My preferred
contact information is found below.

[NOTE TO NAVIGATOR ORGANIZATION AND INDIVIDUAL NAVIGATOR: insert text for any additional
consents that may be requested here.]
IV.

Exceptions or Limitations to Consent

I understand that I can revoke, limit or otherwise change the consents I provide through this form at any time.
If I don’t make any limitations, exceptions, or changes to my consents now, I can still do so at any time in the
future by notifying [Name]. I make the following exceptions, limitations, or changes:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
V.
Additional Information
I understand that:

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1. I don’t have to provide [Name] with any information that I do not want to provide. However, the help
[Name] provides is based only on the information I provide, and if the information given is inaccurate or
incomplete, [Name] may not be able to offer all the help that is available for my situation.
2. I understand that [Name] will ask me to provide only the minimum amount of my PII that is necessary to
help me.
3. [Name] will make sure that my PII is kept private and secure when creating, collecting, disclosing,
accessing, maintaining, storing, and/or using my PII. [Name] will follow the privacy and information
security standards that apply to them.
4. I understand that [Name] is also required to maintain expertise in eligibility, enrollment, and program
specifications for QHPs and insurance affordability programs, and to conduct public education activities to
raise awareness about the Marketplace. [Name] should not need to create, collect, disclose, access,
maintain, store and/or use my PII for these functions. If [Name] does create, collect, disclose, access,
maintain, store and/or use my PII for these functions, [Name] will obtain my consent for those specific
activities. [Name] will keep my PII private and secure except when I have consented to sharing my PII
publicly.
5. If I give my contact information when signing this form, my general consent includes permission for
[Name] to follow up with me about applying for or enrolling into coverage after my first meeting with
them.
6. If [Name] does not have the resources or skills to help me right away, he or she will refer me to another
Marketplace Navigator or in-person assistance personnel, or to the federal Marketplace Call Center, who
can meet my specific needs sooner. If [Name] needs to refer me to another source of help, he or she will
refer me to the source that is easiest for me to access. I understand that [Name] might need to share my
contact information and information about my needs with possible referral sources in order to help me.
7. I understand that once I have signed this authorization form, I can expect [Name] to help me without
asking me to sign another authorization form.
8. [Name] will provide me with a copy of my Authorization Form and this Attachment A, once complete.
9. [Name] is required to collect, handle, disclose, access, maintain, store, and/or use my PII to carry out
activities required under a state law or regulation. [Name] has listed below the specific state requirements
that apply.

[NOTE TO NAVIGATOR ORGANIZATION AND INDIVIDUAL NAVIGATOR: any state requirements that might
require use, disclosure, etc. of consumer PII (for example, state reporting) should be inserted here, if
applicable. Otherwise, this item should not be included on the form.]

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Please, complete, sign, and date the form:

____________________________________________________________________________
Consumer/Consumer’s Legal or Marketplace Authorized Representative Signature
Circle one of these to show if you are the consumer or the consumer’s representative. PLEASE NOTE:
Consumers may sign this consent form themselves, or may choose to have a legal or Marketplace
Authorized Representative sign it.
___________ ____________________________ _________________________________________
Date
Printed Consumer Name
Printed Authorized Representative Name (if applicable)
Ways I agree to be contacted (optional):
__ By mail or in-person at _______________________________________________________________
__ By phone at ___________________ (XXX) XXX-XXXX
__ By text message at _______________ (XXX) XXX-XXXX [Note: to the extent a Navigator entity wishes
to contact individuals on their cell phones or via text message, it should obtain individual legal advice on
what the consent language should say.]
__ By email at ______________________________ XXXXX@XXXXX.XXX

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Attachment A: Roles and Responsibilities of Navigators
1. [Name] must maintain expertise in eligibility, enrollment, and program specifications for qualified health
plans (QHPs) and insurance affordability programs, and must conduct public education activities to raise
awareness about the Marketplace.
2. [Name] must tell me about the full range of QHP options and insurance affordability programs for which I
may be eligible, which includes: providing me with fair, accurate, and impartial information that assists me
with submitting a Marketplace eligibility application; clarifying the distinctions among health coverage
options, including QHPs; and helping me make informed decisions during the health coverage selection
process.
3. [Name] won’t discriminate against me based on my race, color, national origin, disability, age, sex, gender
identity, or sexual orientation.
4. [Name] must provide me with information in a way that that meets my cultural and language needs.
5. [Name] must ensure that tools and help provided are accessible and usable for me if I have disabilities.
6. [Name] must help me to select a QHP, if I want that help, but [Name] can’t and won’t choose a health
insurance plan for me.
7. [Name] must help me with grievances, complaints, or questions about my health plan, coverage, or a
determination under such a plan or coverage, by providing me with referrals to any applicable office of
health insurance consumer assistance or health insurance ombudsman, or any other appropriate state
agency or agencies, if I want that help.
8. All Navigator individuals who help me have been certified by the Marketplace to help consumers after
showing that they meet all required standards, and must follow the terms of [Navigator organization’s]
grant from CMS.
9. All individuals who help me must complete and receive a passing score in a CMS-approved training course
before providing help to consumers, and must take continuing education and be certified or recertified
each year before they can continue to help consumers.
10. [Name] is not a health or stop-loss insurance issuer or a subsidiary of a health or stop-loss insurance issuer,
is not an association that includes members of the insurance industry or lobbies for the insurance industry,
and does not receive any funding or payments from any health or stop-loss insurance issuer in connection
with the enrollment of any individuals in a QHP or a non-QHP. [Name] will also inform me of conflicts of
interest they might have.
11. [Name] must provide me with information about the roles and responsibilities of Navigators, including
through this form.
12. [Name] must comply with Marketplace standards for keeping my PII private and secure, must obtain my
consent before accessing my PII, and must permit me to revoke my consent at any time
13. [Name] will not charge me a fee for any help provided.
14. Beginning on November 15, 2014, [Name] won’t be paid by the Navigator organization based on the
number of applications they help complete, based on the number of people they help, or based on the
number of enrollments they help complete.
15. [Name] won’t give me any gifts (including gift cards or cash) that are over $15 in value, or give me things
that market or promote the products or services of another individual or business, as a way to persuade
me to enroll in health coverage. [Name] is permitted—but not required—to provide me gifts, gift cards, or

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16.
17.

18.

19.
20.

cash that are over $15 in value to reimburse me for things I might have to buy or pay for in order to get
application assistance from [Name] (such as travel or mailing expenses).
[Name] won’t use any funds provided by the Marketplace to buy for me any gifts, gift cards, or things that
market or promote the products or services of another individual or business.
[Name] is not allowed to contact consumers to provide application or enrollment help by going door-todoor or otherwise contacting persons who have not already asked for help, unless [Name] already has a
relationship with a consumer, but [Name] can go door-to-door or contact persons who have not already
asked for help when providing general outreach and education to the public. Because I have a relationship
with [Name], [Name] is allowed to come to my door and/or to call me directly to provide application or
enrollment help, so long as [Name] follows other laws that might apply to that activity.
[Name] is not allowed to make “robo-calls” to consumers (by using an automatic dialing system or prerecorded or artificial voice) unless [Name] already has a relationship with the consumer. Because I have a
relationship with [Name], [Name] is permitted to contact me using “robo-calls” so long as [Name] follows
other laws that might apply to that activity.
[Organization Name] must have a physical location (such as an office) in my state, so that I can get face-toface help if I want it.
[Name] must also meet any applicable state and local requirements when providing services to me.