Disclosure of Health | Active AMS Plans

Affordable Medicare Solutions, LLC

Authorization for Use or Disclosure of Health Information

This document records authorization of disclosure and/or use of individually identifiable health information, as set forth below, consistent with Georgia and Federal law concerning the privacy of such information. Please understand that failure to provide necessary information will preclude our ability to review your coverage.

Use and Disclosure of Health Information

The licensed agent listed below will ONLY use the personal information I provide in my appointment to assist me in reviewing and selecting a Health plan that fits my coverage needs and is available to me. The information will not be used further once my appointment has concluded, or I contact the agent to provide changes or additional information.

Name of Agent

National Producer Number

CHOOSE ONE BOX BELOW:

I authorize that I am the individual or authorized representative listed above. I am completing this form without the assistance of my agent.

I understand and consent that any information I have provided to my agent will be used to select a health plan that is available to me and fits my coverage needs. I also understand that I may rescind this authorization at any time by submitting a written request to Affordable Medicare Solutions, LLC.

OR You may choose:

I authorize that I am the individual or authorized representative listed above.

I do not authorize the agent listed above or Affordable Medicare Solutions, LLC. to use or disclose my information for the purposes of reviewing and presenting Health plans that are available to me. I understand that this may preclude the agent listed above from assisting with enrollment into a Health plan and waive all liability of not having the licensed agent’s assistance.

Signature of Individual / Authorized Representative

Print Name

Signature of Licensed Agent

Select a date

I authorize that the information and answers I have provided in the application are true and complete to the best of my knowledge.

Application Review Date