CAC Form

Organization Name^*

Organization Type^*

How Can the Marketplace Contact Your Organization?

Individual or Organization Name^*

Address Line 1^*

City^*

Address Line 2

State^*

Zip Code^*

Phone Number^*

Email Address^*

How Can the General Public Contact Your Organization?

Phone Number^*

Email Address^*

Website URL^*

Address Line 1^*

City^*

Address Line 2

State^*

Zip Code^*

Organization Details

Do one or all the following apply to your organization? Answer yes or no for all that apply

A non-federal governmental agency?^* Yes No

A health care delivery organization?^* Yes No

Designated by a Medicaid/CHIP agency as a Medicaid/CHIP application assistance program?^* Yes No

Organized under 501(c) of the Internal Revenue Code?^* Yes No

Does your organization already assist people with health care decisions or applications? (Select all that apply)^*

Public Health Programs (i.e. Medicaid, CHIP)
Health Insurance Marketplace
Other health care services

None

Privacy and Security Experience

Does your organization already:

Screen the employees/volunteers it will certify as application counselors in the following ways (Select all that apply)^*

Job/Volunteer application
Background check
Interviews for staff/volunteers
Ensure that staff/volunteers meet Assister requirements under the ACA
Other

None

Handle Personally Identifiable Information (PII) and have policies, operational safeguards (administrative, physical and technical) in place, and have the required training to protect PII?^* Yes No

Complies with the Exchange's privacy and security standards adopted consistent with the ACA (CFR 45 §155.260)

and applicable authentication and data security standards?^* Yes No

Reporting to the Exchange

Agency must maintain a registration process and method to track the performance of certified application counselors.^* Agree Disagree

Provide data and information to the Exchange regarding the number and performance of its certified application counselors and regarding the consumer assistance provided by its certified application counselors, upon request, in the form and manner specified by the Exchange.^* Agree Disagree