HIPAA Authorization Form

PURPOSE OF THIS FORM: This Authorization Form is to be used when an individual wishes to give another person access to his or her information. When completed, it will allow Insurance Service Center - De Pere to disclose your Protected Information to, and receive it from, the person(s) stated on the form. This form does NOT provide any individual, other than a named insured, the rights to make any policy changes on your or behalf (except where allowed by law) nor does it change any contractual agreements between you and your insurance compani(es).

Your Name*

First NameLast Name

Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Your Phone Number*

Area CodePhone Number

Email*

example@example.com

Section 1. Name of the persons or organizations you are authorizing to receive your protected information from Insurance Service Center - De Pere, LLC. (Please note: As part of doing business, ISC will need to share information with the insurance carriers we are working with, so you do not need to specifically the insurance company names)

Name*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Area CodePhone Number

Relationship to You:*

SpouseChildParentOther

*If the person identified is a Power of Attorney (POA) or other legal representative who has paper work identifying their insurance decision-making abilities on your behalf, please submit a copy of that paperwork along with this completed form to Insurance Service Center - De Pere, LLC for review.

Section 2. Information To Be Used or Disclosed

Check one box to describe the insurance information you are authorizing to be used or disclosed:*

ALL: All your information my be disclosed to the person(s) named in section 1 or to Insurance Service Center-De PereSpecific: Only the following specific information about you may be disclosed to the person(s) named in Section 1 or to Insurance Service Center - De Pere

If you chose Specific in the question above please write in the specific information you want to be disclosed.

Section 3. Expiration and Revoaction

This Authorization will remain in effect indefinitely; unless I revoke it.

Right to Revoke: I understand that I may revoke all or part of this authorization at any given time by giving written notice of my revocation to the Privacy Officer at the address listed below. I understand that revocation of this authorization will not affect any action taken in reliance on this authorization before receiving my written notice of revocation. I understand that authorization of this revocation will not take effect until written confirmation is received from Insurance Service Center - De Pere, LLC.

Insurance Service Center - De Pere, LLC

436 Main Ave

De Pere, WI 54115

Section 4. Signatures

I have had full opportunity to read and consider the contents of this authorization, and I confirm that the contents are consistent with my direction to Insurance Service Center - De Pere. I understand that by signing this form, I am confirming my authorization that Insurance Service Center - De Pere may use or disclose to the person or organizations named on this form the information described on this form. I also understand that Insurance Service Center - De Pere will not condition payment, enrollment, coverage, or eligibility for benefits based on information on this form.

I understand that once the information is disclosed pursuant to this authorization, it may no longer be protected by federal privacy laws and could be re-disclosed by the person or entity that receives it.

I am entitled to keep a copy of this form for my records.

Client Signature: (on PC/Laptop use your mouse, on a mobile device, use your finger or stylus)*

If this authorization is signed by a personal representative on behalf of the client, provide a copy of the documentation to support the representation and complete the following:

Printed Name of Personal Representative

First NameLast Name

Relationship to Client

Representative Signature (on PC/Laptop use your mouse, on a mobile device, use your finger or stylus)