Authorization For Release Of Information - Select Account Page 2
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2Member Requested Authorization for Release of Information
Member Information (person granting release of information)
Member Name ______________________________________________________________________
Member ID _________________________________________________________________________
Date of Birth ______/______/________ Group Name: ______________________________________
I authorize SelectAccount to release the following information (check one or more types)
□
Address, date of birth, membership status
□
Account Financial Information (Balances, Deposits, Withdrawals)
□
Claims
□
Other, please specify ______________________________________________________________
SelectAccount may release this information to:
Name _____________________________________________________________________________
Address ___________________________________________________________________________
Phone Number ______________________________________________________________________
Email Address
_____________________________________________________________________
Purpose for this Release
□
Request of member or personal representative
□
Other, please specify ______________________________________________________________
If the information relates to payment for alcoholism or drug dependency expenses, we must have the
name of the treatment facilities or program(s): ______________________________________________
If the information relates to payment for alcoholism or drug dependency expenses, I understand that the
person(s) I have named to receive the information must treat it as confidential. The information cannot
be disclosed again without another signed authorization from me. For all information other than payment
for alcoholism or drug dependency expenses, I understand that the person(s) I have named to receive
information may not be subject to privacy laws. They may be able to release the information, and privacy
laws may no longer protect it.
Right to Revoke - I understand that I may cancel this authorization in writing at any time, but it will not
affect any release of any information processed before I cancel it.
This authorization is valid for one year after the date it is signed, unless an earlier expiration date is
indicated here:________/_________/__________.
______________________________________________________
_______________________
Signature of Member
Date
______________________________________________________
_______________________
Signature of Parent or other Personal Representative
Date
If this request is by a personal representative on behalf of the member, complete the following:
Personal Representative’s Name ________________________________________________________
Relationship to Member _______________________________________________________________
Note: You have a right to keep a copy of this notice after you sign it.
F8977R01 (11/14)
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