CMS-10615 Consent Form

OMB Control Number: 0938-TBD

Attachment C

Healthy Indiana Plan Study

Release of Information

I, ___________________________________________ (please print) give permission to Brightpoint to release my contact and health insurance status information to ______________________________________. I understand that my information will be used for the purpose of coordinating an interview regarding my enrollment in the Healthy Indiana Plan (HIP 2.0).

Address: ______________________________________________

City/Zip: _______________________________________________

Phone Number:_________________________________________

Email Address:__________________________________________

Health Insurance Status: __________________________________

Client Signature: ________________________________________________________