Colonial Supplemental Insurance Disability Claim Form And Instructions (Page 4 of 4) in pdf

Plume 1-800-325-4368

Fax /-800-880-9325

Authorization for Colonial Life

Accident Insurance Company

For the purpose of evaluating my eligibility for insurance and eligibility for benefits under an existing

policy/certificate including checking for and resolving any issues that may arise regarding incomplete or

incorrect information on my application or claim forms, I hereby authorize the disclosure of the following

information about me and, if applicable, my dependents, from the sources listed below to Colonial Life &

Accident Insurance Company (Colonial) and its duly authorized representatives.

Health information may be disclosed by any health care provider or institution, health plan or health

care clearinghouse that has any records or knowledge about me including prescription drug database

or pharmacy benefit manager, or ambulance or other medical transport service. Health information may

also be disclosed by any insurance company, Medicare or Medicaid agencies or the Medical Information

Bureau (MIB). Health information includes my entire medical record and insurance claim history but does

not include psychotherapy notes. Non health information including earnings or employment history or any

other facts deemed appropriate by Colonial to evaluate my application or claim forms may be disclosed

by any entity, person or organization that has these records about me, including but not limited to my

employer, employer representative and compensation sources, insurance company, financial institution or

governmental entities including departments of public safety and motor vehicle departments.

Any information Colonial obtains pursuant to this authorization will be used for the purpose of

evaluating and administering my claim for benefits. Some information obtained may not be protected by

certain federal regulations governing the privacy of health information, but the information is protected by

state privacy laws and other applicable laws. Colonial will not disclose the information unless permitted or

required by those laws.

This authorization is valid for two (2) years from its execution or the duration of my claim,

whichever is earlier and a copy is as valid as the original. I know that I or my authorized representative·

may request a copy of this authorization and access to this information. This authorization may be

revoked by me or my authorized representative at any time except to the extent Colonial has relied on

the authorization prior to notice of revocation or has a legal right to contest coverage under the contract

or the contract itself. If revoked, Colonial may not be able to evaluate my claim or eligibility for benefits. I

may revoke this authorization by sending written notice to: Colonial Life &Accident Insurance Company,

Claims Department, P. 0 Box

100195,

Columbia, SC

29202·3195.

You may refuse to sign this form; however, Colonial may not be able to evaluate and administer

your claim. I am the individual to whom this authorization applies or that person's legal Guardian, Power of

Attorney Designee, Conservator, BenefiCiary or personal representative.

(Printed name of individual

(Social Security Number)

(Signature)

(Date Signed)

subject to this disclosure)

If applicable, I signed on behalf of the insured as

(indicate relationship).

If legal Guardian, Power of Attorney Designee, Conservator, Beneficiary or personal representative.

(Printed name of legal representative)

(Signature of legal representative)

(Date Signed)

Claims Authorization

57644-1

Colonial Supplemental Insurance Disability Claim Form And Instructions Page 4

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