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HIPAA Release of information
I, ____________________________________hereby authorize _______________________ and
its affiliates, its employees and agents (collectively ________________________), to release to
_______________________________ [Insert full name of person/organization] my personal
health information maintained by ___________________ (e.g., information relating to the
diagnosis, treatment, claims payment, and health care services provided or to be provided to me
and which identifies my name, address, social security number, Member ID number) except the
following information about me:
__________________________________ [DESCRIBE INFORMATION NOT TO BE
DISCLOSED, IF ANY] for the purpose of helping me to resolve claims and health benefit
coverage issues. I understand that any personal health information or other information released
to the person or organization identified above may be subject to re-disclosure by such
person/organization and may no longer be protected by applicable federal and state privacy laws.
This authorization is valid from the date of my/my representative’s signature below and shall
expire the earlier of __________________________ [INSERT DATE/EVENT UPON WHICH
THIS AUTHORIZATION EXPIRES] or the date my coverage ends with _________________.
I understand that I have a right to revoke this authorization by providing written notice to
_______________________. However, this authorization may not be revoked if
_______________________, it’s employees or agents have taken action on this authorization
prior to receiving my written notice. I also understand that I have a right to have a copy of this
I further understand that this authorization is voluntary and that I may refuse to sign this
authorization. My refusal to sign will not affect my eligibility for benefits or enrollment or
payment for or coverage of services.
Name of Member: __________________________________________
Signature of Member: _______________________________________
If applicable, Legal Representatives sign below:
By signing this form, I represent that I am the legal representative of the Member identified
above and will provide written proof (e.g., Power of Attorney, living will, guardianship papers,
etc.) that I am legally authorized to act on the Member’s behalf with respect to this
Name of Legal Representative: ____________________________________
Signature of Legal Representative: _________________________________
Name of Witness: ________________________________________
Signature of Witness: _____________________________________
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