By providing my health information to Steinlage Insurance Agency, I authorize the use and disclosure of health information, as described below, and revoke any previous restrictions concerning access to such information:
- Person(s) authorized to use and/or disclose the information: Steinlage Insurance Agency and its agents, employees, or other representatives.
- Person(s) authorized to collect or otherwise receive and use the information: Steinlage Insurance Agency and its agents, employees, or other representatives.
- Description of the information that may be used or disclosed: This authorization specifically includes the release of all information related to my health and/or my insurance policies and claims.
- The information will be used or disclosed only for the following purpose: For the purpose of researching, evaluating, and recommending appropriate insurance plans based on my health and/or insurance policies and claims.
My health information provided to Steinlage Insurance Agency may be protected by state and federal privacy regulations including HIPAA Privacy Rule and that Steinlage Insurance Agency will only use and disclose such information as permitted by applicable regulations. I understand that I may revoke this authorization by not providing my health information, as described above.