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 By signing below, I am granting the authorization and it is my desire to grant BIA this authority which can be rescinded by me at any point.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

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Signed by Christopher Boone
Signed On: June 29, 2021

Signature Certificate
Document name: Authorization for Electronic Assistance Only - Medicare
lock iconUnique Document ID: 6dcb85afdba264a4d331ea85d0fb8fe0c038d77f
Timestamp Audit
September 25, 2019 10:54 am PDTAuthorization for Electronic Assistance Only - Medicare Uploaded by Christopher Boone - [email protected] IP