Confirm your agent of record

If someone changed the agent listed on your Marketplace application without your permission, you can say so in writing here. This page does not know who you are or who sent you the link, and it is only for what you personally know. The form is voluntary, it costs nothing, and you can stop at any point.

The link you opened carries a contact number ending in It is saved with your completed form as a routing reference. It does not identify you, it does not show who sent you the link, and it is not a way to check a caller. It does not say which application is yours — the form asks for that.

The link you opened carries an email address at It is saved with your completed form as a routing reference. It does not identify you, it does not show who sent you the link, and it is not a way to check a caller. It does not say which application is yours — the form asks for that.

Consumer Attestation — Possible Unauthorized Change to My Marketplace Application

Transaction-specific · Voluntary and revocable

This form is for a person who believes the agent of record on their Health Insurance Marketplace application was changed, or that an application was submitted for them, without their permission. Opening this page does not look up your Marketplace records and does not check who referred you. The page cannot tell you whether your agent of record or your application has changed, and a caller's statement, or a link to this form, is not independent confirmation of a change. You may check your Marketplace information yourself before signing, using your own Marketplace account or contact information from the official Marketplace website rather than a number supplied by an unexpected caller. This form lets you state, in your own words, what you personally know. If you choose, you may also authorize the agent or agency you send this form to, to ask the Marketplace/CMS (and, if applicable, a state regulator) to review it. Signing is completely voluntary. This is not authorization to enroll you, change your plan, access your Marketplace account using your credentials, or act as you.

Section 1 — About you

Full name * Best phone

State where you live * ZIP code

If you ask below for your state insurance department to review this, the state you enter identifies which state insurance department that would be. This page does not send that request. Without a state, a state submission cannot be routed and a person has to handle it by hand.

I consent to the agent or agency I send this form to contacting me about this specific matter using my preferred method.

Please do NOT enter your Social Security number or full date of birth on this form.

Section 2 — The application this is about

Marketplace Application ID (if known) Coverage year

Insurance carrier / plan (if known)

Section 3 — My statement, in my own words

Check all that apply based only on what you personally know:

I did NOT authorize any agent other than my chosen agent to be listed as my agent of record. I did NOT authorize a change to my Marketplace application. I did NOT authorize a new application to be submitted on my behalf. I did NOT give consent to be contacted by the other agent or agency about this application. I became aware of this on or around, and here is what happened (your own words):

Section 4 — What I authorize (limited to the application above)

Submit a request, complaint, or supporting information to the Health Insurance Marketplace / CMS asking them to review whether my authorization existed, and attach this attestation. Submit the same or related information to my state Department of Insurance, if applicable. Communicate with me about status, documentation, and resolution of this matter.

This does NOT permit anyone to log into or access my Marketplace account using my credentials, make plan changes for me, or act as me.

Section 5 — What you should know

The agent or agency this form is for — the one whose phone number or email address brought you to this page, and to whom you will send the completed form — may have been (or may claim to have been) your agent of record, and may have its own business interest in this matter. You are signing with that understanding.
Signing is voluntary. You may contact the Marketplace, CMS, your carrier, or your state Department of Insurance directly without signing this form.
This form does not authorize that agent or agency, or VitalBot, to contact another agent with an accusation.
Once you send the downloaded file to the agency that contacted you, your completed form will be delivered to the agent who originally enrolled you, as identified in that agency's own records.

Section 6 — Revocation

I may revoke this authorization at any time in writing. Revocation is effective when received and does not undo submissions already made.

Section 7 — System-detected information

This section is blank because this page does not retrieve records identifying another party. You are not being asked to identify another party, and it does not require you to make any legal conclusion about the other party.

Detected agent/agency now on record (if known)—

Detected NPN / license identifier (if known)—

Detection source / date or report period—

Internal case ID (if applicable)—

Section 8 — Acknowledgment & signature

The statements I have made above are true and accurate to the best of my personal knowledge. I understand that knowingly providing false information in connection with a federal health-insurance matter may have legal consequences.

Type your full legal name to sign

Or sign below:

I agree my electronic signature has the same effect as a handwritten signature, and that the downloaded form records the date, time and time zone reported by my browser and a description of my browser and device.

Pressing the button starts a download; it does not send your completed form to VitalBot or to any agency. Save the file and check that you can open it. You choose whether, and to whom, you send it.

What happens next

You fill in the form and download the completed copy. Check it is on your device, then press Continue.
You send that copy to the agent or agency that contacted you, using contact details you already trusted or looked up yourself. This page does not supply any.
That agent reviews it with you and decides what to do next.

Nothing is sent anywhere when you fill this page in. The completed form downloads to your own device, and you choose who receives it.