Agent Material Request for 2022

Many of the documents you can request here are also available in our broker document library at www.securityhealth.org/brokers. You will also find other important forms like the HIPAA Use and Disclose Protected Health Information Authorization and Authorization to Use and Disclose Protected Health Information for Enrollment and Related Purposes available there for you to download and print. 

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* 1. Today's date

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* 2. Name of individual requesting information

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* 3. Name of your Security Health Plan representative

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* 4. Your phone number

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* 5. Mail materials to this address
(Please note, we cannot deliver to a post office box; a shipping address must be a valid Fed Ex delivery address.)

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* 6. How do you want to receive your packet of documents?

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