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I certify that this disclosure is for the use of my child, the child's sibling, or a family member and I have obtained and reviewed the personal information and I understand that the information I authorize a person or entity to receive may include information regarding a child/minor. I have reviewed this form & have read and understand the information provided. Date: Sign/Date: Date: Confirm: Date: Date: Address 1: Address 2: Address 3: City: State: Zip Code: Country: Telephone: Fax: Email: I've read the above. I agree that I understand, and consent to the use of my personally identifiable health information in accordance with my personal consent. I authorize this used to send any relevant information that is relevant to my child's health and welfare to the Health Insurance Marketplace and may include information about my child's medical history, any health/education expenses, or any treatment that he or she may need. Furthermore, I understand that the information I provide may be shared with other family members and health care providers. Furthermore, I understand that the use of my personal information is not a condition of receiving benefits or making an insurance claim. Furthermore, I understand that the information I provide for the purpose of receiving services or benefits should not be used to authorize the use of another person's health-related information for that purpose; nor can it be used to identify me for commercial purposes (other than the purposes for which I would be providing it). Furthermore, I understand that I can revoke this permission at any time by contacting my child's parents/guardian. Furthermore, I understand that my child/minor can revoke this permission at any time by contacting my parent/guardian. Furthermore, I understand that at any time if I do not want my information to be used for these purposes or a health/educational expense reimbursement (other than the purpose for which the information was provided) I can notify my child's parent/guardian so that this use will no longer be authorized, and I may revoke this authorization. Furthermore, I understand that if my child/minor ever receives a check from the Health Insurance Marketplace to pay for qualified medical or health education expenses, information provided to the vendor by me will remain the property of the Health Insurance Marketplace, and my child/minor will not receive any information that was provided to another entity in conjunction with this health/education reimbursement program.