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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.
OR You may choose:

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