Healthcare Broker Form

HEALTHCARE BROKER FORM

Client Information

Client Name:

Date of Birth:    Gender:

Insurance Information

Medical History (for broker context)

Broker Information

Scope of Authorization

By signing below, the client authorizes the named broker to act on the client's behalf for the following specific activities (check all that apply):

Enrollment and plan selection assistance

Billing inquiries and premium reconciliation

Claims filing, status inquiries, and appeals assistance

Coordination with providers and care management teams

Plan comparisons, benefit explanation, and cost estimates

Authorization Term and Revocation

Effective Date:    Expiration Date:

This authorization remains in effect until revoked in writing by the client.

Revocation: The client may revoke this authorization at any time by delivering a written notice to the broker and to any insurer or provider to whom the authorization was delivered. Revocation will not affect actions taken in reliance on this authorization prior to receipt of the revocation.

Privacy and HIPAA Authorization

I authorize release of my protected health information to the named broker to the extent necessary to carry out the services checked above. This authorization includes, but is not limited to, enrollment records, claims information, explanations of benefits, and other health plan communications. The broker is authorized to receive electronic and paper communications.

I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations. I further acknowledge that the broker is not acting as a healthcare provider and is not responsible for clinical care decisions.

I acknowledge and consent to the release and use of my protected health information as described above.

Compensation and Conflict Disclosure

The broker may receive compensation from insurance carriers, brokers' agencies, or other entities in connection with placement of coverage or services. Compensation arrangements do not alter the client's right to select or change plans. The broker has disclosed known material conflicts of interest as required by applicable law.

I acknowledge receipt of compensation disclosure and understand the broker's potential sources of compensation.

Limitations, Warranties, and Client Responsibilities

The broker will act as a non-clinical representative to assist with administrative, coverage, and enrollment matters. The client remains responsible for providing accurate personal, medical, and insurance information and for reviewing plan materials and making final plan selections. The broker makes no guarantee of coverage, payment, or outcome and disclaims liability for clinical care decisions.

Certification and Acknowledgment

By signing below, I certify that I am the client identified above or the client's authorized representative. I have read this Healthcare Broker Form, I understand its contents, and I authorize the broker to act within the scope and term described. I understand that I may request a copy of this signed authorization.

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