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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:

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

All actions by BIA shall be in accordance with the Medicare.gov Online Services & Web Confidentiality Agreement located here: https://account.mymedicare.gov/help/popup/cms-mbp_oswca_popuphelp.aspx

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 By signing below, I am granting the authorization and it is my desire to grant BIA this authority which can be rescinded by me at any point.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

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