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Get Authorization Of Designated Agent Request Form Optima

Th: Consent is only valid for the specific policies identified by the member ID(s) listed above. Consent is Valid for the length of the Member s Health Insurance Policy unless noted otherwise below: Days 30 Days 60 Days from the date signed by Member below. 90 Days 180 Days 1 Year I hereby authorize Name/Position Address City, State, Zip Phone # to act as my designated agent for the specific purpose of (check all that apply): Receiving information about my claims history (limits, if any) Rec.

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