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206-487-7800 • 1515 N. 200TH ST., SHORELINE, WA 98133

Health Credit Assessment Fields marked with * are required

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You understand that this is not an application for credit and will not effect your credit score * You understand that by providing a signature below, you certify that all the information provided is true and correct, and you are confirming you have read and understand the Privacy Policy and you are providing written instructions to this practice under the FCRA authorizing this practice to obtain information from your personal credit profile from one or more credit reporting agencies. You authorize this practice to obtain such information solely to conduct a prequalification for credit for your health credit assessment.

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Date: 12/21/2024

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