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Get FSL Hospital Confinement Indemnity (GAP) Claim Form 2017-2024

Original. I agree that this Authorization shall be valid for two years from the date shown below. I understand that my providers may not refuse to provide treatment for health care services if I refuse to sign this Authorization. I further understand that if I refuse to sign this Authorization to release my complete medical record, Fidelity Security Life Insurance Company may not be able to make any benefit payments. I understand that I have the right to revoke this Authorization in writing, at .

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