AMU Consent Form This consent form outlines your rights. Please read it carefully. As a licensed Health Insurance Broker, Shamsieh Jahangiri of Lionyx Insurance has completed the annual Affordable Care Act certification by the Marketplace in your state. With this training and formal consent, brokers are authorized to assist with your Marketplace account. This form is to receive your informed written consent. Terms of Consent: I give my permission to Lionyx Insurance, and/or their staff to: Search for an existing Marketplace application Help me apply for Marketplace or Medicaid/CHIP/Tax Credits Provide account maintenance & enrollment help Respond to inquiries from the Marketplace I understand my personal data will be kept secure. This consent stays active until I revoke it in writing by email or mail. Agency Contact Information: Lionyx Insurance | (281) 994-4236 | 22503 Katy Fwy Ste 43, Houston, TX 77450 Agent Contact: Shamsieh Jahangiri | info@lionyxllc.com | NPN: 18708768 First Name * Last Name * Birthdate * ZIP Code * Email * Phone Number I understand that the information I provided is true and correct. I authorize broker Shamsieh Jahangiri (NPN: 18708768) to be listed as broker of record on my Marketplace account. I consent to broker access to my data within my state’s Marketplace exchange. I understand I may revoke access at any time directly through the exchange or by email. Signature (type full legal name) * Submit Consent