ObamaCare (ACA)

Sign your consent form online

Before we can help with your Marketplace enrollment, we need your written permission. Sign below — it takes about a minute and costs nothing.

Go to the form Call (703) 595-4595

Consent

ACA consent form

Your health coverage is handled by Wubeshet Mehari and Wasyihun Workneh. This form gives them your permission to work on your Marketplace enrollment and to send your details to the Marketplace and insurers. It takes about a minute, and there is no charge.

Your licensed agent

Agency handling enrollmentAssisting licensed agentAgent NPN

Pick the agent you have been dealing with. Leave the agency as "Not sure" if you don't know — our team will fill this in.

Full namePhoneEmail (optional)

Please tick each oneI authorize Wubeshet Mehari and Wasyihun Workneh, of Brook Inc. (Brook Tax and Insurance), to help me enroll in a health plan through the Health Insurance Marketplace and to act as my agents for that enrollment.I allow Brook Inc. to share the information I give them with the Marketplace, insurers and brokers whenever it is needed to find and apply for a plan for me.Brook Inc. may contact me by phone, text or email about my coverage, renewals and any documents still needed.The information I gave is accurate and complete to the best of my knowledge. I will report changes in income, household or address. Enrollment help from Brook Inc. costs nothing — the plan premium is set by the Marketplace.

Type your full name to signDate

Please don't write Social Security numbers or medical details here. By signing you agree Brook Tax and Insurance may contact you about your coverage. Call (703) 595-4595 and we'll read your consent back to you.

Questions first? See how we help with ObamaCare (ACA) enrollment.