"Authorization to Release Confidential Health and Claim Information"

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__________________________________________ has requested health and/or claims information concerning
claims submitted and paid for the covered person(s) shown below. Because laws exist to protect the privacy of
confidential health and claims information, we need valid authorization from you, the Covered Person, to disclose
this information to the requesting party. Please sign the following form in the presence of a Notary Public and
return the completed form to the Plan’s claim processor at the address listed on your identification card.
Name of Employer Plan:
____________________________________
Group Number:
____________________________________
Name of Covered Person:
____________________________________
Social Security Number of Covered Person:
____________________________________
Name of Dependent(s)/Birth Date
____________________________________
____________________________________
____________________________________
As the Covered Person under the above-named group health plan, I hereby authorize the Plan’s claim processor
to release the following confidential health and claims related information:
This information may be disclosed to: __________________________, at the following address,
___________________________________________________, whose relationship to the Covered Person is:
___________________________________, for the following purpose(s):
_____ To determine eligibility for benefits, enrollment in a group health plan, or for underwriting
determinations;
_____ For payment of provider claims;
_____ Other: ____________________________________________________
I agree to indemnify and hold the Plan Supervisor harmless for confidential health and/or claims information
released to the named person(s) based upon this authorization.
This authorization will remain valid until the Covered Person is no longer covered under the above-named group
health plan, for two years or until the following date: ________________, whichever occurs earlier.
I understand I may revoke this authorization at any time, upon written notice to the Plan’s claim processor at the
address on my identification card unless either: 1) The Plan’s claim processor has already disclosed my
confidential information in reliance upon this authorization; or 2) this authorization was a condition of my
enrollment in the group health plan.
I understand that the Plan’s claim processor may not condition treatment, payment of claims, enrollment in a
group health plan or eligibility for benefits upon this authorization, UNLESS this authorization is expressly for the
purposes of determining eligibility for benefits, enrollment, or for underwriting or risk rating determinations.
I:\HOME\MKELLER\Auth to release confidential health-claim info 12-16-03.doc
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__________________________________________ has requested health and/or claims information concerning
claims submitted and paid for the covered person(s) shown below. Because laws exist to protect the privacy of
confidential health and claims information, we need valid authorization from you, the Covered Person, to disclose
this information to the requesting party. Please sign the following form in the presence of a Notary Public and
return the completed form to the Plan’s claim processor at the address listed on your identification card.
Name of Employer Plan:
____________________________________
Group Number:
____________________________________
Name of Covered Person:
____________________________________
Social Security Number of Covered Person:
____________________________________
Name of Dependent(s)/Birth Date
____________________________________
____________________________________
____________________________________
As the Covered Person under the above-named group health plan, I hereby authorize the Plan’s claim processor
to release the following confidential health and claims related information:
This information may be disclosed to: __________________________, at the following address,
___________________________________________________, whose relationship to the Covered Person is:
___________________________________, for the following purpose(s):
_____ To determine eligibility for benefits, enrollment in a group health plan, or for underwriting
determinations;
_____ For payment of provider claims;
_____ Other: ____________________________________________________
I agree to indemnify and hold the Plan Supervisor harmless for confidential health and/or claims information
released to the named person(s) based upon this authorization.
This authorization will remain valid until the Covered Person is no longer covered under the above-named group
health plan, for two years or until the following date: ________________, whichever occurs earlier.
I understand I may revoke this authorization at any time, upon written notice to the Plan’s claim processor at the
address on my identification card unless either: 1) The Plan’s claim processor has already disclosed my
confidential information in reliance upon this authorization; or 2) this authorization was a condition of my
enrollment in the group health plan.
I understand that the Plan’s claim processor may not condition treatment, payment of claims, enrollment in a
group health plan or eligibility for benefits upon this authorization, UNLESS this authorization is expressly for the
purposes of determining eligibility for benefits, enrollment, or for underwriting or risk rating determinations.
I:\HOME\MKELLER\Auth to release confidential health-claim info 12-16-03.doc
I understand that any confidential health and/or claims information disclosed to the requesting party in accordance
with this Authorization may be re-disclosed by the requesting party and at that point, would no longer be protected
by this Authorization.
_______________________________
_______________________
Signature of Covered Person
Date
STATE OF __________________
COUNTY OF _______________
Signed and acknowledged by _____________________ who provided proof of identification and who personally
appeared before me, a Notary Public, this ____ day of __________, 20___.
______________________________
(Seal)
Signature of Notary Public
My commission expires _________.
I:\HOME\MKELLER\Auth to release confidential health-claim info 12-16-03.doc
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