Form HBEX404 Authorization for Release of Personal Information by Authorized Representative - California

What Is Form HBEX404?

This is a legal form that was released by the Covered California - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is Form HBEX404?A: Form HBEX404 is the Authorization for Release of Personal Information by an Authorized Representative in California.

Q: What is the purpose of Form HBEX404?A: The purpose of Form HBEX404 is to authorize a representative to access and release personal information on behalf of an individual.

Q: Who can use Form HBEX404?A: Form HBEX404 can be used by individuals in California who want to authorize someone else to access and release their personal information.

Q: What information is required on Form HBEX404?A: Form HBEX404 requires the individual's name, contact information, and the name and contact information of the authorized representative.

Q: Is there a fee associated with submitting Form HBEX404?A: No, there is no fee associated with submitting Form HBEX404.

Q: How long is Form HBEX404 valid?A: Form HBEX404 is valid for one year from the date it is signed, unless otherwise specified.

Q: Can I revoke the authorization granted through Form HBEX404?A: Yes, you can revoke the authorization granted through Form HBEX404 at any time by submitting a written revocation to the authorized representative and the California Health Benefit Exchange.

Q: What should I do if I have questions or need assistance with Form HBEX404?A: If you have questions or need assistance with Form HBEX404, you can contact the California Health Benefit Exchange or seek guidance from a legal professional.