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 Medicare.gov 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 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 By signing below, I am granting the authorization and it is my desire to grant BIA this authority which can be rescinded by me at any point.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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Signed by Christopher Boone
Signed On: September 25, 2019

Boone Insurance Associates https://booneinsuranceassociates.com
Signature Certificate
Document name: Authorization for Electronic Assistance Only - Medicare
Unique Document ID: 3b408cbe3bddb400c6a626813ebd1ec4126199a8
Timestamp Audit
September 25, 2019 10:54 am PSTAuthorization for Electronic Assistance Only - Medicare Uploaded by Christopher Boone - [email protected] IP 199.66.198.50