Insurance Consultation Request and Authorization

Insurance Consultation Request and Authorization
Please fill out the following form to request a consultation with Cornerstone Care Agency to go over options for Insurance or Alternatives for healthcare. Upon completion, someone will reach out to you and go over all your options so you can make an informed decision regarding your coverage for large medical expenses. We look forward to serving you soon.
Are you an individual or employer*
What are you interested in?*
Your Name*
Title*
Date of Birth*

MonthDayYear
Date
Organization Name*
Number of Employees*
Address*

Address

Street Address Line 2

City, State ZipState / Province

Postal / Zip Code
Phone Number*
Email
example@example.com
Notes or Additional Info:
Authorization:

I, the undersigned and authorized representative, hereby authorize Cornerstone Care Agency, with Aaron Scott as the agent of record, to act on behalf of myself, my family, or my organization in the following matters related to our insurance needs:

1. Group Benefits for Employers:
1. Assist in selecting and enrolling in group benefit plans.
2. Provide guidance on benefits available through my employer.
2. Medicare Insurance:
1. Assist with enrollment and plan selection.
2. Provide guidance on benefits and coverage options.
3. Marketplace Insurance:
1. Assist with enrollment in Marketplace plans.
2. Provide guidance on premium tax credits and coverage options.
4. Commercial Insurance or Alternatives for Individuals:
1. Assist with enrollment and plan selection.
2. Provide guidance on benefits and coverage options.
Scope of Authorization:

This authorization allows Cornerstone Care Agency to obtain and share information related to our insurance needs, including but not limited to:
- Personal Health Information
- Insurance eligibility and coverage details.
- Communication with insurance providers on our behalf.
Duration of Authorization:

This authorization is effective immediately and shall remain in effect until revoked in writing by me.

Acknowledgment:

By signing below, I acknowledge that I have read and understand this authorization form. I confirm that I am the person named below and that I am authorized to make this request.
Authorized Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: