Authorization for Electronic Assistance - Medicare
Boone Insurance Associates, Inc.
I, , authorize Boone Insurance Associates, Inc. (“BIA”) to take the following actions on my behalf & be 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 By signing below, I am granting the authorization and it is my desire to grant BIA this authority which can be rescinded by me at any point.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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Your legal name
Your email address
Signed by Christopher Boone
Signed On: January 6, 2020
If you have questions about the contents of this document, you can email the document owner.
Document Name: Authorization for Electronic Assistance - Medicare
Agree & Sign