Consent Forms

Scope of Appointment Confirmation Form

Contact Form - Consent Forms Page

Before meeting with a Medicare beneficiary (or their authorized representative), Medicare requires that Sales Agents use this form to ensure your appointment focuses only on the type of plan and products you are interested in. A separate form should be used for each Medicare beneficiary.

By signing this form, you agree to meet with a Sales Agent to discuss the products checked above. The Sales Agent is either employed or contracted by a Medicare plan and may be paid based on your enrollment in a plan. They do not work directly for the federal government.


Signing this form does not affect your current or future enrollment in a Medicare plan, enroll you in a Medicare plan or obligate you to enroll in a Medicare plan. All information provided on this form is confidential.

Beneficiary or authorized representative signature and signature date:

If you are the authorized representative, please sign above and print clearly and legibly below:

To be completed by licensed sales representative (please print clearly and legibly)

I authorize ACCORD INSURANCE to assist with my Medicare, Social Security and/or Healthcare.gov online account(s) as deemed necessary.

Consent Form for Marketplace Agents and Brokers

Contact Form - Consent Forms Page

give my permission to Kristy Ward 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:

1. Searching for an existing Marketplace application;


2. 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;


3. Providing ongoing account maintenance and enrollment assistance, as necessary; or


4. 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 contacting (405) 410-2440

Name: Kristy Ward

Agent National Producer Number: 6065593

Phone Number: 405-410-2440

Email address: kristy@accordinsurancegroup.com

Name of Primary Household Contact