Authorization for Disclosure of Information Description

This authorization is provided for your use if you wish to have Long Term Care Partners, LLC, disclose your Personal Health Information (PHI) to a designated individual(s). Once you have printed the authorization, please review, complete it and return it to us at the following address:

Long Term Care Partners, LLC
Attn: HIPAA Privacy Office
P.O. Box 797
Greenland, NH 03840-0797

Please understand the completion of this form is completely voluntary. This authorization will allow us to release your Federal Long Term Care Insurance Program (FLTCIP) account information and Personal Health Information (PHI) to the person(s) specified. Please also keep in mind that this authorization concerns your personal records and can only be signed by you or your legal representative (such as a power of attorney, guardian, or conservator).

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