Affiliate Change Form Carebridge Page 4
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4Privacy Statement:
The person who prepares this form states that he or she is the person, authorized officer, or agent of
the person/business for whom these changes would be made under this order. Anyone submitting
false or inaccurate information on this form is subject to punishment by fine or imprisonment or both
under Sections 2, 1001, 1702, and 1708 of Title 18, United States Code.
Attestation, Authorization, and Release:
I hereby release and hold harmless Carebridge Corporation and any and all third parties providing information to
Carebridge Corporation from any liability arising from the release of such information.
I hereby release and hold harmless Carebridge Corporation from any liability arising from its evaluation of
information provided in this form and its credentialing process.
I agree to notify Carebridge Corporation within 10 days of any changes with respect to the information provided
in this application.
I represent and warrant that this application has been completed in good faith and that all information provided
is true, accurate, and complete.
I understand that it is the responsibility of the Affiliate signing this attestation to ensure that all information
reported on this form is factual.
_______________________________________________
______________________________
Signature
Date
________________________________________________
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