Health Information Authorization - Genworth

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Health information authorization
Genworth Life and Annuity Insurance Company,
from
Genworth Life Insurance Company
†
Genworth Life Insurance Company of New York
and
Genworth Life & Annuity
Genworth Life
Genworth Life of New York
Page 1 of 1
P .O. Box 40016
Lynchburg, VA 24506-4016
Th is is a HIPAA compliant authorization
Tel: 888 GENWORTH
(888 436.9678)
• Please print clearly using blue or black ink, and initial any corrections
Fax: 877 300.1280
• Please keep a copy of this form for your records
Policy information
Policy number(s) Use only the spaces needed
▪
Insured name(s)
Birth date(s)
▪
▪
Disclosure authorization
Th e Genworth Financial
You authorize us to use and disclose your health information at your request as designated below.
insurance companies listed above
Requestors List who you authorize to receive your health information
are referred to as “us” and “we” in
▪
this document.
▪
Th e policyholder is referred
to as “you” and “your” in this
▪
document.
▪
Type of authorization Select one
○
At the requestor’s discretion, we will answer any questions about your health information
○
We will only disclose the health information listed below*
Attach a separate, signed sheet of
*Authorized health information for disclosure
paper, if more space is required.
▪
▪
▪
▪
Declaration and signature(s)
Your signature indicates your understanding of the following:
If you are signing as a fi duciary
• You need to keep a copy of this authorization for reference, and acknowledge that a copy of it is
or representative, you must
as valid as the original
sign in capacity and provide
• This authorization will be valid for two years from the date signed
documentation of authority.
• You may revoke this authorization by contacting us in writing
• Your revocation will take effect upon our receipt of your request although it will not include any
information that might have been used or disclosed prior to our receipt of your request
• This authorization allows us to disclose health information to persons or organizations that may
not be subject to federal health information privacy laws, resulting in the information no longer
being protected under such laws
Policyholder signature(s)
Date
X
▪
Printed name of policyholder(s)
▪
†
Only Genworth Life Insurance Company of New York is licensed in New York.
43698 09/17/07

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