For those applying for life insurance coverage with EMC National Life Company: MIB AuthorizationI (we), the Proposed Insured(s) authorize any physician, medical practitioner, health care professional or other health care provider (“Providers”), hospital, medical care facility, the Veteran’s Administration or other medical or medically related facility, insurance company, MIB, LLC (“MIB”), or other organization, institution or person that has any record of information about me to disclose and release the entire medical record and any other protected information concerning such person without restriction to EMC National Life Company or its reinsurers. I authorize EMC National Life Company, or its reinsurer(s), to make a brief report of my personal health or protected health information to MIB. This authorization shall remain in force for 24 months, or as permitted by applicable law in the state where the policy is delivered or issued for delivery, following the date of my signature below, and a photographic copy of this authorization shall be as valid as the original. Medical Authorization&nbsp;I (we), the Proposed Insured(s) authorize any physician, medical practitioner, ("Providers"), hospital, medical care facility, the Veteran’s Administration, insurance company, MIB, LLC, pharmacy benefit manager, pharmacy, a consumer reporting agency, my employer, or any other person or organization that has any record of information about me to release the entire medical record and any other protected information without restriction to [EMC National Life Company (“EMCNL”)], its reinsurers, employers, and authorized representatives information about my health, other insurance coverage, employment, age, general character, finances, participation in hazardous activities, medical care or advice about any physical or mental condition, human immunodeficiency (HIV) infection, sexually transmitted diseases, information about drugs, alcohol, tobacco or other information EMCNL requires to determine insurability or eligibility of benefits. This information is to be disclosed under this Authorization so that EMCNL may: 1) underwrite an application for coverage, make eligibility, risk rating, policy issuance and enrollment decisions; 2) obtain reinsurance; 3) administer claims and provide benefits; 4) administer coverage; and 5) conduct other legally permissible activities that relate to any coverage I have or have applied for with EMCNL.&nbsp;This authorization shall remain in force for 24 months following the date of my signature below, and a copy of this authorization is as valid as the original. I understand that I have the right to revoke this authorization by sending a written request for revocation to EMCNL, [PO Box 9144, Des Moines, IA 50306-9144]. I understand that withdrawal of this authorization is not effective if any Providers have relied on it or if EMCNL has a legal right to contest the insurance policy or a policy claim. I understand that once I authorize disclosure of information to EMCNL, it is no longer covered by federal rules governing privacy and confidentiality of health information (including HIPAA) and may be further disclosed. I understand that the Providers may not refuse to provide treatment if I refuse to sign this authorization. I further understand that if I refuse to sign this authorization to release complete medical records, EMCNL may not be able to process an application for coverage, or if coverage has been issued may not be able to make any benefit payments. I acknowledge that I have received a copy of EMCNL’s Notice of Information of Privacy Practices. I have read this authorization and understand that I or my authorized representative can receive a copy of it. For those applying for life insurance coverage with any other carrier: I authorize MIB and any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, prescription benefit manager, physical therapist, nursing home, mental health care facility, Pharmacy Benefit Manager, Veterans Affairs health care facility, health care facility, electronic health record company, insurer, MIB, database of relevant information, public record, consumer reporting agency, motor vehicle agency or other permissible third-party data source that has provided payment, treatment or services to me or on my behalf (collectively, "My Providers") to disclose my age, entire medical record, medical history, condition, care, prescription drug information, and any other protected health information concerning me for the past 10 years to Amplify Insurance Company, Amplify Life Insurance Company (together, the “Company”), the Company's reinsurers, agents, employees, and Life Insurance Carriers that they are submitting my applications to. This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (“HIV”) infection, Acquired Immune Deficiency Syndrome (“AIDS”) and sexually transmitted diseases. This also includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs and tobacco; employment information and history, including, but not limited to, job duties, earnings, personnel records.By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to this Authorization and I instruct My Providers to release and disclose my entire medical record without restriction.The Company may use this information under this Authorization in accordance with applicable law, including for the purposes specified under its privacy policy, and as applicable so that the Company may:<ol><li>submit and underwrite my application for coverage, make eligibility, risk rating determinations, policy issuance and enrollment determinations</li><li>obtain reinsurance</li><li>administer claims and determine or fulfill responsibility for coverage and provision of benefits</li><li>administer coverage</li><li>conduct other legally permissible activities that relate to any coverage I have, or have applied for or the development of new products or services</li></ol>In addition, the Company, its reinsurers, agents, claims adjudicators, and/or its authorized third party administrators may share protected health information received under this Authorization with MIB, LLC and further use this information to adjust the rates I am charged and/or rescind my coverage.This Authorization shall remain in force for 24 months following the date of my signature below, and a copy of this Authorization is as valid as the original. I further understand that this Authorization takes priority over any agreements I have made with My Providers to restrict my protected health information, and I therefore instruct My Providers to release and disclose my entire medical records or knowledge of me or my health without restriction. I also understand that any information that is disclosed pursuant to this Authorization may be redisclosed and no longer covered by certain federal rules governing privacy and confidentiality of health information.I have the right to revoke this Authorization in writing, at any time, by sending a written request for revocation to Amplify Life Insurance at 2261 Market Street STE 5482 San Francisco, CA 94114. I understand that a revocation is not effective to the extent that the Company or any of My Providers have relied on this Authorization or to the extent that Amplify Insurance Company has a legal right to contest a claim under an insurance policy or to contest the policy itself. I understand that if I refuse to sign this Authorization Amplify may not be able to process my application, or if coverage has been issued, Amplify Insurance Company may not be able to make any benefit payments.

HIPAA Compliant Authorization for Life Insurance