Directory Results for AUTHORIZATION TO OBTAIN AND DISCLOSE INATION Application Number of Proposed Insured Name of Proposed Insured (Please Print or Type) (A) The terms that follow have the respective meanings when used in this Authorization to AUTHORIZATION TO OBTAIN AND DISCLOSE INATION Proposed Insureds Name Date of Birth Social Security Number This form is HIPAA compliant Records and information obtained from the Proposed Insured or other parties may be disclosed to and