Authorization for Release of Health Information to: Senior Life Insurance Company P.O. Box 2447 Thomasville, GA 31799-2447 |
This Authorization complies with the HIPAA Privacy Rule
I hereby authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, pharmacy benefit manager, medical facility, insurance company, insurance support organization (such as Medical Information Bureau, Inc.) or other health care provider that has provided payment, treatment or services to me or on my behalf (“My Providers”) to disclose my entire medical record and any other protected health information concerning me to Senior Life Insurance Company (the “Company”) and its agents, employees, and representatives. This includes information on the diagnosis or treatment of HIV (Human Immunodeficiency Virus), AIDS (Acquired Immune Deficiency Syndrome), sexually transmitted diseases, information on the diagnosis and treatment of mental illness and the use of alcohol, drugs and tobacco, but excludes psychotherapy notes.
I acknowledge that any agreements I have made to restrict my protected health information do not apply to this Authorization and I instruct My Providers to release and disclose the entire medical records without restrictions
This protected health information is to be disclosed under this Authorization so that the Company may:
- underwrite my application for coverage, make eligibility, risk rating, policy issuance and enrollment determinations;
- obtain reinsurance;
- administer claims and determine or fulfill responsibility for coverage and provision of benefits;
- administer coverage;
- conduct other legally permissible activities that relate to any coverage I have or have applied for with the Company.
I understand that My Providers may not refuse to provide treatment or payment for health care services if I refuse to sign this Authorization. I further understand that if I refuse to sign this Authorization to release my complete medical records, the Company may not be able to process my application, or if coverage has been issued, may not be able to process policy claims and/or make any benefit payments. I am entitled to receive a copy of this Authorization. My Personal Representative is also entitled to receive a copy of this Authorization.
I have read or have been read all questions and answers, and I affirm that they are true to the best of my knowledge and belief. I understand that for insurance to go into effect, the Proposed Insured’s health condition must remain as described in the application at the time the first premium is honored by the bank and the policy is issued. I also understand that Senior Life Insurance Company will rely on my answers above in issuing any life insurance hereunder and that the agent does not have the authority to waive or modify any question or answer. Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.