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Consent Confirmation*
(Member [you], Parent, Caregiver or Legally Authorized Representative of Member)

This form will send your message to Superior HealthPlan as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with Superior through email, you accept the risks associated thereof. Superior does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your protected health information (PHI), please send us a message through the Secure Member Portal or Provider Portal, or you can call us at the Member Services number on the back of your Superior ID card to speak directly to a customer service representative.

By communicating with Superior HealthPlan via email, you give consent to receive information from Superior, which may contain PHI, to your email address. This consent is not required. Communication via email is not as secure as communicating via our secure member portal. If you do not want to receive email responses, please let us know.