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Apply to be a Certified application counselor organization

All fields are required

Basic Information

(Let us know if your organization is a community health center, HRSA Health Center, recipient of a HRSA grant for enrollment assistance, library, or other type of organization.)

How can the Marketplace contact your organization?

How can the general public contact your organization?

( Example: http://www.yourwebsite.org )

Organization details

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

Privacy and Security Experience

Does your organization already:



PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1205. The time required to complete this information collection is estimated to average one hour per application, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact 1-800-318-2596.