Below are “Sample” consent templates that you can save in your Consent On Demand account.
Click here to view instructions on how to create a template.
Please note that you are responsible to check with your own legal counsel as to the legality of a template meeting any state or federal requirement.
CMS ACA New Client Consent Template
Client Changes Template
Medicare Scope of Appointment Template
New Client Review – Confirm Accuracy
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I, <> <>, give my permission to <> <>, to serve as the health insurance agent or broker for myself and my entire household if applicable, for purposes of enrollment in Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for one or more of the following:
I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.
I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes.
I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by email and/or written letter.
I, <<Contact.FirstName>> <<Contact.LastName>>, have reviewed and confirm that I authorized <<User.FirstName>> <<User.LastName>>, to make the following changes on my behalf and that these changes are accurate.
Change 1:
Change 2:
Change 3:
Change 4:
I, <<Contact.FirstName>> <<Contact.LastName>>, have reviewed and confirm that that the eligibility application is accurate and I approve <<User.FirstName>> <<User.LastName>> to submit on my behalf.
I appoint <<User.FirstName>> <<User.LastName>> to act as my representative in connection with my claim or asserted right under Title XVIII of the Social Security Act (the Act) and related provisions of Title XI of the Act. I authorize this individual to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with my claim, appeal, grievance or request wholly in my stead. I understand that personal medical information related to my request may be disclosed to the representative indicated below.
In making this request, <<User.FirstName>> <<User.LastName>> hereby accepts the above appointment, certifies that he/she has not been disqualified, suspended, or prohibited from practice before the Department of Health and Human Services (HHS); that he/she is not, as a current or former employee of the United States, disqualified from acting as the party’s representative; and that he/she recognizes that any fee may be subject to review and approval by the Secretary. He/she is an agent.
We will be discussing the following plan types:
– < Plan 1 >
– < Plan 2 >
– < Plan 3 >
– < Plan 4 >
You must be entitled to Medicare Part A and enrolled in Medicare Part B. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or another third-party.
By signing this form you are agreeing to a sales meeting with a sales agent to discuss the specific types of products indicated above. The person that will be discussing plan options with you is either employed or contracted by a Medicare health plan or prescription drug plan that is not The Federal government, and they may be compensated based on your enrollment in a plan.
Signing this form does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare plan.
Charging of Fees for Representing Beneficiaries before the Secretary of HHS
An attorney, or other representative for a beneficiary, who wishes to charge a fee for services rendered in connection with an appeal before the Secretary of HHS (i.e., an Administrative Law Judge (ALJ) hearing or attorney adjudicator review by the Office of Medicare Hearings and Appeals (OMHA), Medicare Appeals Council review, or a proceeding before OMHA or the Medicare Appeals Council as a result of a remand from federal district court) is required to obtain approval of the fee in accordance with 42 CFR 405.910(f).
The form, OMHA-118, “Petition to Obtain Approval of a Fee for Representing a Beneficiary” elicits the information required for a fee petition. It should be completed by the representative and filed with the request for ALJ hearing, OMHA review, or request for Medicare Appeals Council review. Approval of a representative’s fee is not required if: (1) the appellant being represented is a provider or supplier; (2) the fee is for services rendered in an official capacity such as that of legal guardian, committee, or similar court appointed representative and the court has approved the fee in question; (3) the fee is for representation of a beneficiary in a proceeding in federal district court; or (4) the fee is for representation of a beneficiary in a redetermination or reconsideration. If the representative wishes to waive a fee, he or she may do so. The form, OMHA-118, may be found at: https://www.hhs.gov/sites/default/files/OMHA-118.pdf
Approval of Fee
The requirement for the approval of fees ensures that a representative will receive fair value for the services performed before HHS on behalf of a beneficiary, and provides the beneficiary with a measure of security that the fees are determined to be reasonable. In approving a requested fee, OMHA or Medicare Appeals Council will consider the nature and type of services rendered, the complexity of the case, the level of skill and competence required in rendition of the services, the amount of time spent on the case, the results achieved, the level of administrative review to which the representative carried the appeal and the amount of the fee requested by the representative.
Conflict of Interest
Sections 203, 205 and 207 of Title XVIII of the United States Code make it a criminal offense for certain officers, employees and former officers and employees of the United States to render certain services in matters affecting the Government or to aid or assist in the prosecution of claims against the United States. Individuals with a conflict of interest are excluded from being representatives of beneficiaries before HHS.
Where to Send This Form
Send this form to the same location where you are sending (or have already sent) your: appeal if you are filing an appeal, grievance or complaint if you are filing a grievance or complaint, or an initial determination or decision if you are requesting an initial determination or decision. If additional help is needed, contact 1-800-MEDICARE (1-800-633-4227, TTY users call 1-877-486-2048), or your Medicare plan.
You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit https://www.medicare.gov/about-us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users can call 1-877-486-2048.
Punch List Summary:
Confirmation of Work Completion
Client Statement:
I, <<Contact.FirstName>> <<Contact.LastName>> confirm that all punch list items have been satisfactorily completed as per the contract specifications and requirements.
Contractor Statement:
I, <<User.FirstName>> <<User.LastName>> of <<Account.AccountName>> confirm that all punch list items have been completed and reviewed with the client.
Project Name:
Project Number:
Customer: <<Contact.FirstName>> <<Contact.LastName>>
Company: <<Account.AccountName>>
Description of Change:
Reason for Change:
Cost Adjustment
The total cost adjustment due to this change is:
No change in cost
Increase in cost: $__________
Decrease in cost: $__________
Revised Total Contract Amount: $__________
Time Adjustment
The total adjustment to the project timeline due to this change is:
No change in timeline
Increase in time: __________ [days/weeks]
Decrease in time: __________ [days/weeks]
Revised Completion Date: ___________________________
Acknowledgements
The undersigned acknowledge and agree to the terms of this Change Order. This Change Order is incorporated into and subject to the terms of the original contract agreement.
Project Name:
Project Number:
Client/Customer Name: <<Contact.FirstName>> <<Contact.LastName>>
Contractor/Company Name: <<Account.AccountName>>
Description of Work Approved
The undersigned acknowledges and approves the completion of the following deliverables or project phase(s):
Work/Deliverables Approved:
Project Name:
Project Number:
Client/Property Owner Name: <<Contact.FirstName>> <<Contact.LastName>>
Contractor/Company Name: <<Account.AccountName>>
Project Address: <<Account.Address>>, <<Account.City>>, <<Account.State>>
Acknowledgement of Payment
The countersigned, <<User.FirstName>> <<User.LastName>> of <<Account.AccountName>> acknowledges receipt of payment in the amount of $[Payment Amount] for labor, materials, and services provided for the project described above.
Waiver of Lien Rights
<<Account.AccountName>> waives and releases any and all lien rights against the property located at <<Account.Address>>, <<Account.City>>, <<Account.State>> for the amount received as payment and for the work completed and full completion of the project
Final Lien Waiver: This waiver applies to all payments received and releases all lien rights for the entire project.
Conditions of Waiver
This waiver is conditioned upon the receipt of actual payment in full for the amount listed above. If payment is not honored (e.g., a check is returned or payment is otherwise invalid), this waiver becomes null and void.
I, <<Contact.FirstName>> <<Contact.LastName>> acknowledge receipt of this Final Lien Waiver and understand any retraction of payment will invalidated this waiver.
Project Name:
Project Number:
Client/Customer Name: <<Contact.FirstName>> <<Contact.LastName>>
Contractor/Company Name: <<Account.AccountName>>
Acknowledgement of Final Payment
This document serves as confirmation that the <<Contact.FirstName>> <<Contact.LastName>> has made the final payment for the project referenced above. <<Account.AccountName>> acknowledges receipt of the final payment and confirms that all financial obligations under the terms of the contract have been fulfilled.
Payment Details
Total Contract Amount: $
Previously Paid Amount: $
Final Payment Amount: $
Payment Method:
Cash
Check (Check Number: )
Bank Transfer (Reference Number: )
Credit/Debit Card
Other:
Release of Liens and Claims
<<Account.AccountName>> confirms that no outstanding balances remain and agrees to release the <<Contact.FirstName>> <<Contact.LastName>> from any further claims, liens, or financial obligations related to the project. A lien waiver may be provided upon request.
Project Name:
Project Number:
Client/Property Owner Name: <<Contact.FirstName>> <<Contact.LastName>>
Contractor/Company Name: <<Account.AccountName>>
Project Address: <<Account.Address>>, <<Account.City>>, <<Account.State>>
Acknowledgement of Payment
The countersigned, <<User.FirstName>> <<User.LastName>> of <<Account.AccountName>> acknowledges receipt of payment in the amount of $[Payment Amount] for labor, materials, and services provided for the project described above.
Waiver of Lien Rights
<<Account.AccountName>> waives and releases any and all lien rights against the property located at <<Account.Address>>, <<Account.City>>, <<Account.State>> for the amount received as payment and for the work completed up to [Date]
Partial Lien Waiver: This waiver applies only to payments received to date and does not waive lien rights for future unpaid work.
Conditions of Waiver
This waiver is conditioned upon the receipt of actual payment in full for the amount listed above. If payment is not honored (e.g., a check is returned or payment is otherwise invalid), this waiver becomes null and void.
I, <<Contact.FirstName>> <<Contact.LastName>> acknowledge receipt of this Partial Lien Waiver and understand any retraction of payment will invalidate this waiver.
This Release of Liability Agreement (“Agreement”) is entered into between <<Contact.FirstName>> <<Contact.LastName>> (“Participant”) and <<Account.AccountName>> (“Provider”).
1. Activity Description
The Participant acknowledges that they are voluntarily participating in [Activity/Sport Name], taking place on [Date] at [Location]. The activity may involve physical exertion, inherent risks, and unforeseen hazards that could result in personal injury or property damage.
2. Assumption of Risk
The Participant understands and agrees that participation in the activity is inherently dangerous and assumes all risks associated with the activity, including injuries, accidents, and property damage.
3. Release of Liability
The Participant releases, waives, and discharges the Provider, its employees, agents, contractors, and representatives from any and all claims, liabilities, or demands arising from or related to participation in the activity, including those caused by negligence.
4. Indemnification
The Participant agrees to indemnify and hold harmless the Provider from any claims, damages, or expenses (including attorney’s fees) resulting from their participation in the activity or their actions.
5. Medical Consent
The Participant consents to emergency medical treatment if necessary and releases the Provider from any claims related to such medical care, including costs or outcomes.
6. Equipment and Safety
The Participant agrees to follow all safety instructions and use any provided equipment responsibly. The Participant acknowledges that improper use of equipment may result in additional risks.
7. Photography and Media Release
The Participant grants the Provider permission to use photographs, videos, or recordings taken during the activity for promotional or informational purposes in any format.
8. Governing Law
This Agreement shall be governed by and construed in accordance with the laws of << Account.State >>, and any disputes shall be resolved under these laws.
This Release of Liability Agreement (“Agreement”) is entered into by and between <<Contact.FirstName>> <<Contact.LastName>> (“Releasor”) and <<Account.AccountName>> (“Organizer”).
1. Event Description
The Releasor acknowledges that they are voluntarily participating in [Event Name] (the “Event”), taking place on [Date] at [Location]. The Event may include activities that involve risks, including but not limited to personal injury, property damage, or other unforeseen hazards.
2. Assumption of Risk
The Releasor understands and accepts that participation in the Event carries inherent risks. By signing this Agreement, the Releasor voluntarily assumes all risks associated with attending and participating in the Event, including but not limited to risks caused by the actions or negligence of the Organizer, other participants, or third parties.
3. Release of Liability
The Releasor agrees to release, waive, and discharge the Organizer, its affiliates, employees, contractors, agents, and representatives from any and all claims, liabilities, or demands arising from or related to participation in the Event, including but not limited to those caused by negligence.
4. Indemnification
The Releasor agrees to indemnify and hold harmless the Organizer from any claims, damages, or expenses (including attorney’s fees) resulting from participation in the Event or actions taken by the Releasor.
5. Medical Treatment
The Releasor consents to receive emergency medical treatment if deemed necessary during the Event and releases the Organizer from any claims related to such medical care, including costs and outcomes.
6. Photography and Media Release
The Releasor grants the Organizer permission to use photographs, videos, or recordings taken during the Event for promotional, advertising, or informational purposes in any media format.
7. Governing Law
This Agreement shall be governed by and construed in accordance with the laws of <<Account.State>>, and any disputes shall be resolved under these laws.
This Release of Liability Agreement (“Agreement”) is entered into by and between <<Contact.FirstName>> <<Contact.LastName>> (“Releasor”) and <<Account.AccountName>> (“Releasee”).
1. Acknowledgment of Risk
The Releasor acknowledges and agrees that participation in [describe activity or event] may involve inherent risks, including but not limited to personal injury, property damage, or other potential hazards. The Releasor voluntarily assumes all such risks, whether known or unknown, arising from their participation.
2. Release of Liability
In consideration of being permitted to participate in [activity/event], the Releasor releases, waives, and discharges the Releasee, their employees, agents, officers, and affiliates from any and all claims, demands, liabilities, or causes of action that may arise from participation in the activity, including but not limited to those caused by the negligence of the Releasee.
3. Indemnification
The Releasor agrees to indemnify and hold harmless the Releasee from any and all claims, liabilities, damages, or expenses (including reasonable attorneys’ fees) arising from or related to the Releasor’s participation in the activity/event.
4. Medical Treatment
The Releasor consents to receive medical treatment deemed necessary in the event of injury or illness during the activity/event. The Releasor releases the Releasee from any claims related to medical care, including costs or consequences arising from the treatment.
5. Binding Effect
This Agreement shall be binding upon the Releasor, their heirs, assigns, and legal representatives. It is intended to be as broad and inclusive as permitted by applicable law.
6. Governing Law
This Agreement shall be governed by and construed in accordance with the laws of <<Account.State>>. Any disputes arising under this Agreement shall be resolved under these laws.
7. Entire Agreement
This Agreement constitutes the entire understanding between the parties and supersedes any prior agreements or understandings. Any modifications must be made in writing and signed by both parties.
This Agreement is made between <<User.FirstName>> <<User.LastName>>, (“Photographer”) and <<Contact.FirstName>> <<Contact.LastName>>, (“Model”).
1. Grant of Rights
The Model grants the Photographer and their legal representatives, licensees, and assigns the irrevocable and unrestricted right to use and publish photographs or videos of the Model taken on [shoot date(s)] at [location(s)], for any lawful purpose, including but not limited to advertising, promotion, marketing, and editorial use, in any medium now known or hereafter developed.
2. Compensation
The Model will receive compensation in the amount of $
3. Ownership
The Photographer retains full copyright and ownership of all photographs and videos taken during the shoot. The Model waives any claims to ownership or financial gain from the images or videos.
4. Model Representations
The Model confirms that:
• They are of legal age (or the parent/guardian has signed below if under 18).
• They have the authority to enter into this Agreement.
5. Release and Waiver
The Model releases the Photographer and their legal representatives, licensees, and assigns from any and all claims and demands arising out of or in connection with the use of the photographs or videos, including without limitation any claims for invasion of privacy, defamation, or misuse.
6. Agreement Modification
This Agreement constitutes the entire agreement between the parties. Any modification must be in writing and signed by both parties.
7. Governing Law
This Agreement shall be governed by the laws of the State of <<Account.State>> and the United States of America.
This Agreement is made between <<User.FirstName>> <<User.LastName>>, (“Photographer”) and <<Contact.FirstName>> <<Contact.LastName>>, (“Model”).
1. Grant of Rights
The Model grants the Photographer and their legal representatives, licensees, and assigns the irrevocable and unrestricted right to use and publish photographs or videos of the Model taken on [shoot date(s)] at [location(s)], for any lawful purpose, including but not limited to advertising, promotion, marketing, and editorial use, in any medium now known or hereafter developed.
2. Compensation
The Model acknowledges and agrees that no monetary compensation is due for the use of the images or videos as described in this Agreement.
3. Ownership
The Photographer retains full copyright and ownership of all photographs and videos taken during the shoot. The Model waives any claims to ownership or financial gain from the images or videos.
4. Model Representations
The Model confirms that:
• They are of legal age (or the parent/guardian has signed below if under 18).
• They have the authority to enter into this Agreement.
5. Release and Waiver
The Model releases the Photographer and their legal representatives, licensees, and assigns from any and all claims and demands arising out of or in connection with the use of the photographs or videos, including without limitation any claims for invasion of privacy, defamation, or misuse.
6. Agreement Modification
This Agreement constitutes the entire agreement between the parties. Any modification must be in writing and signed by both parties.
7. Governing Law
This Agreement shall be governed by the laws of the State of <<Account.State>> and the United States of America.
This Agreement is between <<Contact.FirstName>> <<Contact.LastName>> (“Photographer”) and <<Contact.FirstName>> <<Contact.LastName>>, (“Subject”).
1. Permission to Use Photographs
The Subject grants the Photographer and their legal representatives, licensees, and assigns the irrevocable and unrestricted right to use and publish photographs or images of the Subject for any lawful purpose. This includes but is not limited to use in advertising, promotional materials, social media, editorial publications, websites, and other media formats, in both digital and print formats.
2. Ownership
The Photographer retains full copyright and ownership of all photographs taken. The Subject waives any claims to ownership, compensation, or financial gain from the use of the photographs.
3. Compensation
The Subject acknowledges and agrees that no monetary compensation is due for the use of the images. Any agreed-upon compensation or services will be outlined separately and are not part of this Release.
4. Release and Waiver
The Subject releases the Photographer and their legal representatives, licensees, and assigns from any claims or liabilities arising from the use of the photographs, including claims of defamation, invasion of privacy, or any misuse of the images.
5. Editing and Alteration
The Photographer may edit, modify, crop, or otherwise adjust the photographs as necessary for their intended purpose, provided the changes do not misrepresent or harm the Subject’s image or reputation.
6. Duration of Agreement
This release is perpetual and does not expire. The Photographer may use the photographs indefinitely unless otherwise agreed upon in writing.
7. Agreement Modification
This Agreement constitutes the entire understanding between the parties. Any changes or modifications must be made in writing and signed by both parties.
8. Governing Law
This Agreement shall be governed by and construed in accordance with the laws of <<Account.State>>, and any disputes shall be resolved under these laws.
This Agreement is between <<User.FirstName>> <<User.LastName>>, (“Producer”) and <<Contact.FirstName>> <<Contact.LastName>>, (“Participant”).
1. Permission to Use Video Footage
The Participant grants the Producer and their legal representatives, licensees, and assigns the irrevocable and unrestricted right to record, use, reproduce, and publish video footage featuring the Participant. This includes the Participant’s image, voice, and likeness for any lawful purpose, including but not limited to advertising, promotional materials, educational content, and media productions in any format.
2. Ownership
The Producer retains full ownership and copyright of all video footage and recordings. The Participant waives any claims to ownership, royalties, or financial compensation for the use of the video footage.
3. Purpose and Scope
The video footage may be used for purposes such as:
• Commercial advertising
• Promotional materials
• Social media posts
• Educational or informational content
• Media broadcasts
• Other lawful purposes in any medium (digital or print) now known or hereafter developed.
4. Compensation
The Participant acknowledges and agrees that they will not receive monetary compensation for the use of the video footage unless otherwise agreed upon in a separate written agreement.
5. Release and Waiver
The Participant releases the Producer, their legal representatives, licensees, and assigns from any claims, liabilities, or demands arising from the use of the video footage, including claims of defamation, invasion of privacy, or misrepresentation.
6. Editing and Alteration
The Producer may edit, modify, or adapt the video footage as necessary for its intended use, provided such changes do not misrepresent or harm the Participant’s image or reputation.
7. Duration of Use
This release is perpetual and does not have an expiration date. The Producer may use the video footage indefinitely.
8. Agreement Modification
This Agreement constitutes the entire understanding between the parties. Any modifications must be made in writing and signed by both the Participant and the Producer.
9. Governing Law
This Agreement shall be governed by and construed in accordance with the laws of <<Account.State>>. Any disputes shall be resolved under these laws.
Social Media Release Form
This Agreement is between <<Contact.FirstName>> <<Contact.LastName>> (“Releasor”) and <<User.FirstName>> <<User.LastName>>, (“Releasee”)
1. Permission to Use Content
The Releasor grants the Releasee full permission to use the following content: photographs, videos, text/written content, and any other media provided. This content may be used by the Releasee on all social media platforms, including but not limited to Instagram, Facebook, TikTok, LinkedIn, Twitter, and others.
2. Purpose of Use
The content may be used for advertising, promotion, informational or educational purposes, general social media updates, and any lawful purpose as deemed appropriate by the Releasee.
3. Duration of Use
This release is perpetual and does not have an expiration date. The Releasee may use the content indefinitely.
4. Compensation
No monetary compensation will be provided for the use of the content. The Releasor acknowledges and agrees that the release of content is voluntary and does not involve financial payment or remuneration.
5. Ownership and Attribution
The Releasor retains ownership of the original content. The Releasee agrees to credit the Releasor when using the content by providing appropriate attribution, such as tagging or mentioning the Releasor’s social media handles or name, whenever possible.
6. Release and Waiver
The Releasor releases the Releasee from any and all claims, liabilities, or demands arising from the use of the content on social media platforms, including but not limited to claims of defamation, invasion of privacy, or misrepresentation.
7. Content Alteration
The Releasee is permitted to edit, modify, or adapt the content as necessary for use on social media platforms, provided that the edits do not misrepresent or harm the Releasor’s image or reputation.
8. Agreement Modification
This Agreement constitutes the entire agreement between the parties. Any modifications to this Agreement must be made in writing and signed by both the Releasor and the Releasee.
9. Governing Law
This Agreement shall be governed by and construed in accordance with the laws of <<Account.State>>, and any disputes arising under this Agreement shall be resolved in accordance with these laws.