HIPPA Authorization Form

HIPAA AUTHORIZATION TO USE OR DISCLOSURE OF PERSONAL, MEDICAL AND INSURANCE INFORMATION

HIPPA AUTHORIZATION TO USE OR DISCLOSURE OF PERSONAL MEDICAL INSURANCE INFORMATION FORM

Your Legal Name:

Date of Birth:

Last Digits of SS#:

Email:

Phone:

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At my request, I give Brackett Consultants Inc. dba Brackett Insurance Consultants

(PolicyHunters.com) permission to discuss (verbal, email or text) all details related to health, dental, life or Medicare insurance (and tax subsidies if applicable) for myself and any immediate family members and dependent children that would/could be included on the same policy. The person(s) listed below also has my permission to complete an application, choose a plan and make initial payment. I understand that I am personally responsible for all decisions made by the person(s) listed.

I have read and understood the CONSUMER CONSENT POLICY available at https://www.policyhunters.com/consumer-consent-policy and am extending that same to the person(s) listed below on my behalf. I do understand that this consent will remain active unless revoked via email to info@PolicyHunters.com.

Extending permissions to:

Extending permissions to:

Legal Name:

Relationship:

Email:

Phone:

Legal Name:

Relationship:

Email:

Phone:

Signature:

Today's Date:

You may also click here to download a copy of the HIPAA AUTHORIZATION TO USE OR DISCLOSURE OF PERSONAL, MEDICAL AND INSURANCE INFORMATION form.

HIPAA AUTHORIZATION TO USE OR DISCLOSURE OF PERSONAL, MEDICAL AND INSURANCE INFORMATION

HIPPA AUTHORIZATION TO USE OR DISCLOSURE OF PERSONAL MEDICAL INSURANCE INFORMATION FORM

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