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Life Insurance Awareness Month

Wednesday Sep 1 - Thursday Sep 30


Sunday, Oct 31 All Day

Christmas Eve

Friday, Dec 24 All Day


Saturday, Dec 25 All Day

If you need to review the "Enrollment Info", please click here.

Please read this Disclosure, type your name at the bottom of the page, and then click Submit (if you agree to the terms of the disclosure). Once you submit this form, you will be redirected a page that will allow you to access our enrollment website.

If you would like a PDF copy of this Disclosure, please click PII & PHI Disclosure.pdf.

Courter Financial Services, LLC

478 Jacksonville Road | Bellefonte, PA 16823

Phone: 814-355-3380 | Fax: 814-357-8033

Privacy Disclosure for Protected Identifiable Information (PII) and Protected Health Information (PHI)

Agent Information:

Name: Justin P Doherty                             FFM User ID: DIS.JPD

Website:           NPN: 15671034

By submitting this form, I acknowledge receipt of this PII & PHI Disclosure. By completing an application on the enrollment website, I give my permission to the agent(s) and/or staff members indicated above to inform me and/or my authorized representative about my health coverage options in the Marketplace, to help me apply for and enroll in health coverage through the Marketplace (if I choose to do so), and/or help with a grievance, complaint, or question about my health plan, coverage, or a determination under such a plan or coverage. I understand that in giving this consent, that the agent(s) and/or staff members indicated above will need to see or use some of my personally identifiable information or personal health information in order to provide this assistance.

In this consent form:

>whenever it says "I", "me", or "my", "I", "me", or "my" includes my authorized representative if I have one.

>personally identifiable information is called PII

>personal health information is called PHI

>health plans available through the Marketplace are called Qualified Health Plans ("QHP;s")

>whenever it says "agent", "agent" includes any additional agents and/or staff members as indicated above

I understand and agree that:

>the agent cannot choose a health insurance plan for me.

>I do not have to provide the agent with more information that I choose to provide.

>the agent may be compensated by receiving a commission if I choose to purchase a QHP or other coverage.

>this authorization includes the PII and/or PHI for any person that appears on my enrollment application.

>any applicable fees or charges will be communicated to me by the agent prior to any services being rendered so that I have the opportunity to decline such services.

>I may cancel my consent in writing at any time and will notify the agent if I choose to cancel my consent. I understand that once I have submitted this disclosure form, I can expect the agent to help me without asking me to submit another disclosure form.

>I will not hold the agent responsible for any negligent act or consequence of any negligent act as long as the agent acted within reason by relying solely on the information that was provided to him/her in the event that such information was inaccurate or incomplete.

>the agent will help me to the best of his/her/their ability by telling me about the full range of QHP options and insurance affordability programs for which I may be eligible, and will help me with grievances, complaints, or questions about my health plan, coverage, or a determination under such a plan or coverage, if I want that help.

>the agent will make sure that my PII and/or PHI are kept private and secure when creating, collecting, disclosing, accessing, maintaining, storing, and/or using my PII and/or PHI and/or the PII of my authorized representative.

>the agent may create, collect, disclose, access, maintain, store, and/or use my PII and/or PHI, and or the PII of my authorized representative, only in order to perform the duties of an agent, and may not re-use that PII and/or PHI for any other purpose(s) (unless specifically requested by me).

>the duties of an agent include any/all of the following: 1) Providing information and services in a fair and accurate manner. This information should include the full range of QHP's that are available as well as other programs such as Medicaid and CHIP. 2) Facilitate the selection of a QHP, including following up with me on applying for or enrolling in coverage, if I consent to having the agent follow up with me. My consent is given by providing my phone number and/or email address below. 3) Providing referrals to any applicable office of health insurance consumer assistance or appropriate state agency for any enrollee with a grievance, complaint, or question about his/her health plan, coverage, or a determination made under such a plan or coverage.

>the help the agent provides is based only on the information I choose to provide, and if the information I have provided is inaccurate or incomplete, the agent may not be able to offer all of the help that may be available to me for my situation.

CFSLLC_PII_PHI_Disc                               Page 1 of 1                               Revision 11-05-2015

If you have already submitted your Disclosure and need the web address for our enrollment website, please call us at 1-888-669-5591.

Please type your Full Name*

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