Authorized Representative

Authorized Representative
Use this form to authorize a representative to discuss health insurance plan options on your behalf with an agent at Teague Financial. This discussion may include your personal, financial information, date of birth, social security number, address, physician choice, personal health information, plan benefits, rates, household income, household size, marital, employment and citizenship status.

This is not a Power of Attorney. This form is limited to discussing plan options before enrollment.

The authorized representative is unable to: Complete enrollment forms on your behalf. Speak directly with the insurance carrier without proper documentation or verbal consent.

Once your enrollment is complete, Teague Financial will be unable to share any HIPAA (Health Insurance Portability and Accountability Act) or health plan information with the authorized representative without proper legal documentation.
Applicant
Name*
Phone Number*
Email*
example@example.com
Address*
Authorized Representative
Name*
Phone Number*
Email*
example@example.com
Address*
Relationship to Applicant*
I, the Applicant, authorize Teague Financial to speak to my Authorized Representative on my behalf regarding the information above until my enrollment is complete.
Applicant Signature*

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Date*

MonthDayYear
Date
Authorized Representative Signature*

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Date*

MonthDayYear
Date
Should be Empty:

Applicant