Florida Hipaa Release Form

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					UAatWork Supply Order Form                                   Page 1 of 4                                                              0209




                              UNITED AMERICAN INSURANCE COMPANY

                         BRANCH OFFICE                 UAatWork            SUPPLY ORDER FORM
    3700 S. Stonebridge Drive, McKinney, Texas • www.unitedamerican.com • E-Mail: agentsupply@torchmarkcorp.com • Fax: 469-525-4290


  PLEASE NOTE: Most materials are available online for immediate download (DOWNLOAD NOW)
  and may not available through Supply. Applications are available through state Compliance Sheets.
  Material availability may vary by state. Please refer to your state's Compliance Sheet or Product
  Approval Chart before ordering.

  STEP 1: Fill in the yellow and blue boxes below. All information is required. Please complete a
  separate UAatWork Supply Order Form for each state where you are licensed.



  AGENT NUMBER       BRANCH NAME                                                         BRANCH NUMBER          ORDER DATE



  YOUR NAME                                                                                                     # LICS. AGENTS

                                                                                                                 For which state
  STREET ADDRESS (REQUIRED FOR GROUND DELIVERIES)                                        SUITE                   you are
                                                                                                                 requesting
                                                             STATE                                               forms?
  CITY                                                                                   ZIP

                                                                                                                 STATE
  E-MAIL ADDRESS                                             CELL PHONE



  OFFICE PHONE                                               FAX

                                                                                                      BOD         F4397 R0910
  STEP 2: Enter the quantity your are requesting to the right of each item. Then e-mail the completed
  form as an attachment to agentsupply@torchmarkcorp.com. (From the "File" menu above, select
  "Send To", then select "Mail Recipient as Attachment".)


  AGENT TRAINING MATERIALS
    • UAatWork Agent Manual F4341                                                                               DOWNLOAD ONLY
    • UAatWork Section 125 Agent Reference Guide F4997                                                          DOWNLOAD ONLY
    • UAatWork New Business Workflow F5335 CS                                                                   DOWNLOAD ONLY
    • Section 125 Employer Implementation Manual F4500

  WORKSITE MARKETING ADVERTISING MATERIALS
    • UAatWork Presentation Folder F4340
    • UAatWork Enrollment Poster F4398
    • UAatWork Program Advertising Brochure F4435
    • UAatWork Section 125 Employer Brochure F4496
    • UAatWork Section 125 Employee Brochure F4497
    • UAatWork Print Ad - Products UAW-1                                                                        DOWNLOAD ONLY
    • UAatWork Approach Letters USM-1                                                                           DOWNLOAD ONLY
    • UAatWork Approach Letters USM-2                                                                           DOWNLOAD ONLY
    • UAatWork Approach Letters USM-3                                                                           DOWNLOAD ONLY
    • UAatWork Approach Letters USM-4                                                                           DOWNLOAD ONLY
UAatWork Supply Order Form                       Page 2 of 4                                        0209


  CASE SUBMISSION FORMS
    • New Payroll Deduction Case (After-Tax) PDF Packet                                 DOWNLOAD ONLY
    • New Section 125 Case (Pre-Tax) PDF Packet                                         DOWNLOAD ONLY
    • Amend an Exisiting Section 125 Case (Pre-Tax) PDF Packet                          DOWNLOAD ONLY
       The PDF Packets above include all relevant forms, which are also listed below:
       • Acceptance of Payroll Deduction F4348 B                                        DOWNLOAD ONLY
       • Plan Adoption Agreement EIM-001                                                DOWNLOAD ONLY
       • Salary Reduction Form EIM-002                                                  DOWNLOAD ONLY
       • Points to Remember EIM-003                                                     DOWNLOAD ONLY
       • Premium Reduction Amendment EIM-004                                            DOWNLOAD ONLY
       • Payroll Deduction Authorization F4349                                          DOWNLOAD ONLY
       • Payroll Deduction Cancellation F4350                                           DOWNLOAD ONLY
       • New Business Transmittal Form F4351                                            DOWNLOAD ONLY
       • Request for Contingent Guarantee Issue F4715                                   DOWNLOAD ONLY
       • Consumer Form 3728                                                             DOWNLOAD ONLY


  REQUIRED FORMS
    • Life and Health Privacy and Disclosure Booklet UAPDI F5616
    • HIPAA Release Authorization F3978
    • Rated Premium Rider Worksheet U-1280 WSM                                          DOWNLOAD ONLY



  PRODUCT MATERIALS
  Where approved, applications and other required forms can be downloaded from your state's
  Compliance Sheet. Select your state from the drop down menu displayed on the web page.
  UAMM
    • Application UAMM[XX]                                                              DOWNLOAD ONLY

    • Optional Dependent Form UAMM-ODF[XX]                                              DOWNLOAD ONLY

    • Health Rate Card F4434[XX]                                                        DOWNLOAD ONLY

    • Life Rate Book F4702[XX]                                                          DOWNLOAD ONLY


    Foundation (MMGAP/R-MMGAP-HO)
    • Product Brochure F6546[XX]                                                        DOWNLOAD ONLY

    • Outline of Coverage DS-MMGAP[XX]                                                  DOWNLOAD ONLY

    • Marketplace Bulletin F6608 WSM MMGAP                                              DOWNLOAD ONLY


    Life - 20 Year Renewable Term & Term to 100 (UATPTL/UATGC)
    • Product Brochure F6550                                                            DOWNLOAD ONLY

    • Marketplace Bulletin F6604 WSM UAPTL                                              DOWNLOAD ONLY

    • Marketplace Bulletin F6605 WSM UAPTGC                                             DOWNLOAD ONLY
UAatWork Supply Order Form                   Page 3 of 4                     0209


  UACB PRODUCT MATERIALS
    • Application UACB[XX]                                       DOWNLOAD ONLY

    • Optional Dependent Form UACB-ODF[XX]                       DOWNLOAD ONLY

    • Health Rate Card F4701[XX]                                 DOWNLOAD ONLY
    • Life Rate Book F4702[XX]                                   DOWNLOAD ONLY


    Accident Compensation (UA-250)
    • Product Brochure F4432[XX]                                 DOWNLOAD ONLY

    • Outline of Coverage DS-UA250                               DOWNLOAD ONLY



    Cash Cancer (CANB)
    • Product Brochure F4430[XX]                                 DOWNLOAD ONLY

    • Outline of Coverage DS-CANB[XX]                            DOWNLOAD ONLY



    Cancer Expense (CAXC)
    • Product Brochure F4703[XX]                                 DOWNLOAD ONLY

    • Outline of Coverage DS-CAXC[XX]                            DOWNLOAD ONLY



    Critical Illness (CILS)
    • Product Brochure F4431[XX]                                 DOWNLOAD ONLY

    • Outline of Coverage DS-CILS[XX]                            DOWNLOAD ONLY



    Life - 20 Year Renewable Term & Term to 100 (UATPTL/UATGC)
    • Product Brochure F6550                                     DOWNLOAD ONLY

    • Marketplace Bulletin F6604 WSM UAPTL                       DOWNLOAD ONLY

    • Marketplace Bulletin F6605 WSM UAPTGC                      DOWNLOAD ONLY


  UAHI PRODUCT MATERIALS
    • Application UAHI[XX]                                       DOWNLOAD ONLY

    • Optional Dependent Form UAHI-ODF[XX]                       DOWNLOAD ONLY

    • Health Rate Card F4387[XX]                                 DOWNLOAD ONLY



    Protector Series I (HMXC)
UAatWork Supply Order Form                       Page 4 of 4                             0209


    • Product Brochure F4346[XX]                                             DOWNLOAD ONLY

    • Outline of Coverage DS-HMXC[XX]                                        DOWNLOAD ONLY



    Protector Series II (HIXC)
    • Product Brochure F4347[XX]                                             DOWNLOAD ONLY

    • Outline of Coverage DS-HIXC[XX]                                        DOWNLOAD ONLY



  UA PARTNERS DISCOUNT MEDICAL PLAN FORMS
    • Partners Plus Worksite Enrollment form F6692WS                         DOWNLOAD ONLY
    • UA Partners with Provider Network Option Worksite Enrollment F6693W2   DOWNLOAD ONLY
    •   UA Partners Worksite Enrollment Form F6694WS                         DOWNLOAD ONLY
    •   UA Partners Stand Alone Worksite Enrollment Form F6696WS             DOWNLOAD ONLY
    •   NetConnect Worksite Enrollment Form F6697WS                          DOWNLOAD ONLY
    •   UAatWork UA Partners Enrollment Form F4300( R)                       DOWNLOAD ONLY
    • Mail Order Program Agent Guide F4505-T                                 DOWNLOAD ONLY

    • UA Partners 24-Hour NurseLine Pamphlet F2940
    • UA Partners Travel Assist Pamphlet F2941

  DENTAL - Security Life APEX
    • Agent Guide S10978                                                     DOWNLOAD ONLY
    • Group Enrollment Form S10649                                           DOWNLOAD ONLY
    • Voluntary Group Dental - Adoption and Participation Agreement S10941   DOWNLOAD ONLY
    • Voluntary Group Dental Plans - Florida (Letter Size) S10970            DOWNLOAD ONLY
    • Voluntary Group Dental Plans - Florida (Tabloid Size) S10971           DOWNLOAD ONLY
    • Voluntary Group Dental Plans - Plan Descriptions S10961                DOWNLOAD ONLY
    • Voluntary Group Dental Plans (Letter Size) S10950                      DOWNLOAD ONLY

				
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Description: Florida Hipaa Release Form document sample