Fill and Sign the Clinic Intake Form

Opt-Out Request Form Send to: HSBC P. O. Box 12405 Wilmington, DE 19850 Please do not include any other correspondence with your request, and do not include this form with your payment. By checking the appropriate box (es) below, completing the requested information, and returning this form, you are requesting that we do not share your information (except as permitted or required by law), or that we do not allow our Affiliates to use your information for marketing purposes. This request applies only to the policy number(s) designated below. Sharing with our Affiliates: I do not want my credit information shared with other Affiliates. This request will not apply to the sharing of information about my transactions or experience with Affiliates (e.g. policy information, policy usage or payment history.) Note: Credit information about Vermont residents is not shared with Affiliates. Sharing with Non-Affiliates: I do not want my non-public personal information (e.g. name and address) shared with Non-Affiliates. I understand that this may prevent me from receiving valuable offers. This request will not apply to the sharing of information that is permitted or required by law. Note: Information about California and Vermont residents is not shared with Non-Affiliates. Limiting marketing by Affiliates: I do not want your Affiliates to use my personal information for marketing purposes. My policy number is: Please print clearly.  Additional policy numbers: Name (as it appears on your policy Address City State (____) Telephone Number Please allow sufficient time for us to process your opt-out request(s). HSBC-10 Zip