I authorize the use and disclosure of individually identifiable health information that I submit in my insurance coverage story, including but not limited to names, dates, costs and medical conditions, to any Consumers for Fair and Affordable Insurance Reform (CFAIR) member.

I understand that my insurance coverage story may be examined by the CFAIR member to determine whether it can be used for legislative testimony and education, media stories, and/or advertising purposes. I understand that the CFAIR member may contact me for additional information and may disclose this additional information to other CFAIR members.

Note: If your protected health information is disclosed under your authorization to persons or organizations not subject to federal privacy laws, it may be re-disclosed and is no longer protected.

I agree that this authorization will not result in any healthcare insurance coverage and that my treatment, payment, enrollment or eligibility for healthcare insurance benefits will not be conditioned on whether I sign this authorization.

This authorization expires on 9/1/08. I understand that I can revoke this authorization at any time by clicking here. I also understand that revocation will not affect actions taken before receipt of my request.