Claim Form Hippa - 10-830 (Page 3 of 3) in pdf

Protective

Life Insurance

Company

Claims Department

PO BOX 667

FLUSHING MI 48433-0667

AUTHORIZATION

TO OBTAlN AND DISCLOSE

INFORMATION

FOR EVALUATION

OF CLAIM

I__

Date of Birth

HlPAA

(2/11)

Name of Insured or Deceased

Certificate

Number

1. Authorization

and Purpose.

,(circle

one) the Insured,

Personal

Representative

the Insured

or the deceased named above, authorize Protective Life Insurance Company ("Protective")

and its reinsurers to

obtain and use information about or relating to the Insured that is relevant to evaluating a claim for benefits from a Protective

policy ("Policy") insuring the Insured. With this authorization, Protective may obtain and use health and medical information,

including but not limited to information about drug use, alcohol use, nicotine use, physical diseases and illness. With this

authorization, Protective may also obtain information about mental diseases and illness including psychiatric disorders, but any

such information

shall not include psychotherapy

notes.

2_ Persons and Organizations

Authorized

to Release and Disclose Information.

I authorize the following persons and

organizations to release and disclose the information described in Section 1 ("Information")

to Protective or its agents acting on

its behalf: (i) doctor(s); (ii) medical practitioners; (iii) pharmacists, to include Pharmacy Benefit Managers; (iv) medical and

related facilities, including hospitals, clinics, facilities run by the Veteran's Administration,

The Cleveland Clinic Foundation and

The Mayo Clinic; (v) insurers; (vi) reinsurers; (vii) Medical Information Bureau, Inc. (MIB); (viii) employers of the Insured; and

(ix) commercial consumer reporting agencies (CRA). All of these persons and organizations

other than MIB may release the

Information to a CRA (such as Equifax Medical Services) acting for Protective. MIB may not release the Information to a CRA.

I authorize Protective personnel who obtain or who otherwise have authorized access to the Information to release and disclose

any such Information to its reinsurers, the Insured's insurance agent or agents servicing the Policy or Policies and persons or

organizations,

including Protective affiliated companies, providing to Protective services related to claims administration

including legal and investigative services.

3. Expiration

of this Authorization.

This authorization shall be valid from the date signed for the duration of a claim for the

benefits of a Protective Policy.

This authorization shall expire twenty-four months from the date this authorization is signed.

4. Revocation

of this Authorization.

I understand that I have the right to revoke this authorization

by writing to

Claims

Department, P.O. Box 790, Deerfield, IL 60015.

I also understand that revocation of this authorization

will

not

affect any action

taken in reliance on this authorization before Protective receives written notice of the revocation

nor will/he revocation be

effective

to the extent other law provides Protective with the right to contest a claim under the Policy or the Policy itself.

Signature

and Date of Authorization

I have had full opportunity to read and consider the contents of this authorization. I understand that I may refuse to sign this

authorization and that Protective does not condition payment of a claim for benefits on whether or not I sign this authorization.

I further understand that pursuant to the Policy, Protective is eligible to require written proof of loss in order to process a claim

under the Policy.

I understand that by signing this form I am granting to Protective the authority to obtain, use and disclose Information as

described and for the purposes stated in this form. I further understand that if the persons or organizations

I authorize to obtain or

use the Information obtained or used through this authorization are not subject to federal health information privacy laws, they

may disclose the Information, and it may no longer be protected by the federal health information privacy laws.

Signature:

Date: ::-

--::--:-

(Circle One) Insured, Personal Representative

or Personal Representative

of the Deceased Person named above.

WARNING:

"Any person who knowingly

presents a false or fraudulent

claim for payment

of a loss or benefit or knowingly

presents false information

in an application

for insurance

may be guilty of a crime and may be subject to civil fines and

criminal penalties."

YOU ARE ENTITLED

TO A COPY OF THIS AUTHORIZATION

AFTER YOU SIGN IT.

HIPAA (2111)

Claim Form Hippa - 10-830 Page 3

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