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3 - RETURH

Tl*lS PAGEI

Hadleal Dslsrtmont
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lledical Relea+e Form f#lum lo comrJffe fiorrr ln fls snffmtr mef delev-*ftr.eflt defiamfnrtisn *ndoevms*rf af clrlra
, TE: ,d

iir. GARRTT
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KEARNS

Fax: Date: 17 Oct 2O12

Re: Mr. GARRETT KEARNS

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iim tie r;' u As i64ga 3 e

erniit;

lnsured

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, Date of B*rih:l&t{ov-1999
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t-6oS- 775-+??6,

, Email:andyckeams@gmai*.conr

lnsured's Clty:

State: , ?

Country:.

l1eatifg !?T*r.Si{ .6.hul}fi"trn144 Phvsician

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Horfle

Doctor

Clry:JACK$ON

State: NH ZIP Code:03846

Phons: flS3f3379S6

Fnmary

I f.lirnet : Pho*e; Narne,

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tnsurance

, Addre*s:

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ln*urance

gCsignitec ontscl
Person

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cC " ' Address: fr'r >t AN*P" - t S t I f( Fnone: i - 8(, 6 -4 oo * lto z

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1(" 2p6

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Fax:

Retarronship:

p*r*ee J

[ps X cf 3 - RETURiI Tl+lC P*GE)

l{edlcal Dep*rkn*nt - 24 hosra

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Plrsrar {"eff5&?bB$ flJS & tffadBl ore: !.71 F*4S{E35 Cdlsrt suB&ic U$i
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Fat*cnt ll*rna; llir. GARfiTT PANEHT FARE}IT

Ca*q l{umbrr: UAS1$4S836

T SIGH BLO{iI: AUTI{OREATIH TO REL=A$E THFORl*ATIoii

Travel Giusrd ls tie Flsn sdrnlnlrlrtor for yaur Trevel lncureilee tnd s{ll be coor6l:r*tlng rsimbureoment fsr digibk medlcal .xpsnass foc thls indivldual. I hsve rGrd the forego*ng and the anrtrer* provlded are true and conpl*te to the bact of my hnowledge.
I heleby authsrize any insuranca 6onlp*ny, prepayma*t organization, employer, hscpital, or Fhysiei*n to raleac all informstion with respect 1o me or any of my dependonts wtrich rnay have a bearl*g on the henefits payable undar thi$ or any athar plan providing benefils sr :ervices. I herely eertify ihe infsrmatisn providad is eonecl and trua to lhe basl of my knowledge. t furlher aulhorize the parties ligted above to disclosa my protacted haaltft informatisn {FHl}. including eopie* af rny medical records and regular verbat raport, to:

Travel Guard Assist

Atandm: lt dlc* hpqtncnt S300 BuslnanPerk Or. Sbwns Point, Wl54482 USA To[ Frs:l-877-2f&7OG!

lnfl Go$ac* +l 7tf 348 0835

A,n

p*r,s Vuno^s

t!f,3d3-RErunfilHBP|GC)

Copy Le$sr Prtnt1VfiAI2012 12:52:58

lledical Drpartment - 24 houre Fhme.

1

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Fhoil*: 1-71$34&{E3S tBollsct {iibirt* US}

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Ffi{ 1-252-36.{-2!03

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lnrured'a lnformation Lefter

From: Re: Mr. GARRETT

TravalGuard KmRHS

Ernail; qqdp!9qm9@-ggg!l_.,c1grn,

: Data: 17 Oet 2012

W* *re plersed tE be of *isistance to you through tfrie diffieult time. tffe wculd like ts m*flnn the infannation given
to you during cur initisl convarsation. Wo provide as$istanc for ff:e travel inaurane pclicy lhat ycu purchared. In order to make arangsmeRts go as efrciently as posslble, *e would like to outline *orne hetptul lnfarmatian"

t"

W* wlll

We rrrill refur ts your cag by your last name andlor by Case I'lurnbgr; U48104883 lf, due to your condltion or ho*pl,lal procedures rue are u*ehle to communicate wilh you direetly, we will cornmunicale with your deeignee. Oue to ecnfidentlatity of your situation. your derlgnee will be required ta idntify hinfherself by their name and your case nunrber. Our medlcrl statr rlll mcnltor irour case btr a rerls3 af scheduled con*ultgEon* wlEe your trsstl*g

l*

provtdlng you rt*ih

2{-hour mrdicrl er*r* msrrg*rftrnt:

?hyrici*n" Your trreting phy*ician will rtqulrc your *uthorkatisn to ral**sr your mrdical lniormatlen to ur.

ll r*qulred Infonratsen regardlng be*efta

and bllllng Inttruc*onc ut*lt be *ent to your iroatlng pilyrlclan.

The tollowln+ ns*dr to be returned to ogr el|lc*

bililLImlll:

. ' '
VSe c

Cepy ol original sirline itinerary (or 6opy of papar tickets. if applieablc) fr{adical Rrleese Form {attached}-cornpleted and signed Photocopy of your pas$Bort (if oiltside of the USA)

-rtainly hope that our serviceg will help ycu dfid your family mernbers through $ie difficult tima. For any queelions that you may have. eonlect us by Email or at the telepnsne numbers fisted, referring ts your ease number

9481048i36"
Sincsrely, Gh*stin iloly Medical Assistanc Department

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Patlant

iladicat Depcrfincnt - 2a fiourf Ftrsp:1-8.?7-F+700f g,ruA0sdal

Phore: f-?1F3{&083t {C"olbc*orlbid*

Far 1-3G!-36t1-I203

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G*FfifTT l(EARilg

Ga*e Humbar: U481S,08836