Affiliate Realtor Recording Request
Use this form to submit a request to receive a copy of the voice recording for any referral you have submitted that was marked "unqualified"
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Realtor Name
Name of Referral
Name of Referral
Name of Referral
HIPPA COMPLIANCE
By requesting a copy of this recording you acknowledge your Business Associate relationship with D2C Insurance Group under the Health Insurance Portability and Accountability Act (HIPPA) and that you will ensure the protection of this Protected Health Information (PHI) as required by HIPAA and the HIPAA Privacy and Security Rules. This includes, but is not limited to, your use or disclosure of this PHI only as permitted or required by law, and for the sole purpose of verifying insurance eligibility status for submitted referrals per the Realtor Affiliate Agreement. Any use or disclosure of PHI outside the agreed-upon purposes will terminate our Business Associate relationship and will be reported immediately.

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