Initial Statement Of Claim Disability Benefit Page 2
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3P.O. Box 7749
Philadelphia, PA 19101-7749
AUTHORIZATION FOR USE IN OBTAINING INFORMATION
NAME OF INSURED: _________________________________________________
INSURED'S SSN: ___________________________________________________
POLICYHOLDER: ___________________________________________________
To all physicians and other health care professionals, hospitals, other health care
institutions, insurers, medical, hospital and prepaid health plans, pharmacies,
employers, group policyholders, contract holders, governmental agencies (including but
not limited to the Social Security Administration), private and/or public benefit plan
administrators, and/or attorney representatives, including but not limited to covered
entities and business associates under the Health Insurance Portability and
Accountability Act of 1996 (“HIPAA”) and the accompanying regulations:
You are authorized to provide Reliance Standard Life Insurance Company and/or its
authorized administrators with information concerning medical care, advice, and/or
treatment provided to me, the above named Insured, and/or any employment, salary
and/or benefit-related information concerning me, the above named Insured.
I
understand that the disclosure of information may include disclosure of protected
health information under HIPAA and the accompanying regulations, information
regarding treatment for mental illness, the human immunodeficiency virus (HIV) and/or
the use of drugs and alcohol. I also understand that information used or disclosed
pursuant to this authorization may be subject to redisclosure by the recipient and will
no longer be subject to protection under HIPAA and the accompanying regulations. A
statement of Reliance Standard Life Insurance Company’s privacy policy is available at
or upon request.
I understand that any such information will be used for the purpose of evaluating my
claim for benefits. Upon request, I understand that I am entitled to receive a copy of
this Authorization. This Authorization is valid from the date signed for the duration of
the claim, and may be revoked by me at any time upon written request to the address
above.
A reproduction of this Authorization shall be considered as valid as
the
original.
_________________________
___________________________________
Date
Insured's Signature
(If the Insured is unable to sign, an authorized person may sign.)
__________________________
___________________________________
Date
Authorized Person's Signature
Description of Authorized Person’s authority to sign on behalf of Insured:
___________________________________________________________________
EF-1029
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