Authorization for Electronic Assistance - Medicare

Boone Insurance Associates, Inc.

Authorization for Electronic Assistance - Medicare


I, , authorize Boone Insurance Associates, Inc. (“BIA”) to take the following actions on my behalf & be agent of record on my account:

  1. To assist with the creation of a my account and use my information to review and/or update my account;
  2. To access my Personally Identifiable Information (“PII”) for the purpose of assisting with the Medicare plan determination and/or plan enrollment; and
  3. To be listed as the agent of record on my account.


All actions by BIA shall be in accordance with the Online Services & Web Confidentiality Agreement located here:


I have read and understand the nature of this Authorization. By signing below, I am granting the authorization and it is my desire to grant BIA this authority which can be rescinded by me at any point.


Agency: Boone Insurance Associates

Managing Agent: Chris Boone

Managing Agent NPN:8008427

Leave this empty:

Signature arrow sign here

Signed by Christopher Boone
Signed On: June 29, 2021

Signature Certificate
Document name: Authorization for Electronic Assistance - Medicare
lock iconUnique Document ID: dfdf97f65cb42a0a33e46f1a7a18d067ff6a5ec2
Timestamp Audit
September 24, 2019 5:15 pm PDTAuthorization for Electronic Assistance - Medicare Uploaded by Christopher Boone - [email protected] IP