Form A - Applicant Information For Comprehensive Protection Plan Page 4
Download a blank fillable Form A - Applicant Information For Comprehensive Protection Plan in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form A - Applicant Information For Comprehensive Protection Plan with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4Liberty Life Assurance Company of
Boston
Group Benefits Disability Claims
P.O. Box 7206
London, KY 40742-7206
Phone: 800-210-0268
Fax: 603-334-0401
Authorization to Obtain and Release Psychotherapy Notes
EMPLOYEE NAME:
CLAIM NO:
EMPLOYER/SPONSOR/CUSTOMER NAME:
RETURN TO: Dover Claims
I authorize any physician, health plan, health care professional, mental health professional, hospital, clinic, medical facility, other
health care providers, government agency and any insurance or reinsurance company to release any psychotherapy notes relating to
me to the particular Company in the Liberty Mutual Group of companies to which I am submitting a claim, or to its agents,
employees, or representatives, or to the Plan Sponsor (if Self Insured Plan), or to persons or other organizations providing claims
management services.
By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to
this Authorization, and I instruct any physician, health plan, health care professional, hospital, clinic, medical facility, other health
care provider, government agency, and any insurance or reinsurance company to release and disclose all of my psychotherapy notes
without restriction, including psychotherapy notes recorded in any medium documenting or analyzing the contents of conversations(s)
during private counseling sessions and/or group, joint or family counseling sessions.
I understand the Company or Plan Sponsor will use the information obtained under this Authorization or directly from me to
determine eligibility for insurance benefits, which may include assessing ongoing treatment. Any information obtained will not be
released to any person or organizations EXCEPT to the Plan Sponsor, reinsuring companies, other companies in the Liberty Mutual
Group of companies to which I am submitting a claim, Employee Assistance Programs (EAP) or other disease management or
assistance programs providing services to the Plan Sponsor and/or to the Company, persons or other organizations providing claims
management and claim advisory services to the Plan Sponsor and/or to the Company, the Group Policyholder and its agents/vendors
for purposes of auditing the Company’s administration of claims under the policy and/or assessing statistical claim data related to its
benefit programs, persons or organizations providing medical treatment or services in connection with my claim, or any person
performing business or legal services for them in connection with my claim(s) or as may be otherwise permitted or required by law. I
also understand that, to the extent reasonably necessary, information obtained may be released to other insurance companies or
insurance support organizations to detect or prevent criminal activity, fraud, material misrepresentation, or material non-disclosure in
connection with insurance transactions.
I understand that the Company must comply with state and federal laws and regulations enacted to protect my privacy. I also
understand that the information disclosed to them pursuant to this Authorization may be subject to redisclosure with my authorization
or as otherwise permitted or required by law.
I understand that this Authorization is valid for two years from the date appearing below with my signature. I understand that I have a
right to request and receive a copy of this Authorization. I agree that a photographic copy of this Authorization shall be as valid as the
original. I understand that I have the right to revoke this Authorization at any time by written notification to the Plan Sponsor and/or
the Company in the Liberty Mutual Group of companies for which I submit a claim. I understand that revocation will not apply to any
information that is requested prior to Liberty receiving notice of revocation.
I understand that if I refuse to sign this Authorization to release all of my psychotherapy notes or if I alter or revoke it, the Company
may not be able to process my claim for benefits and may not be able to make benefit payments.
Claimant Name ( Print)
Date of Birth
Claimant Signature
Date
_______________________________________________
Claim Number:
DP 432 Psych (rev 06/12)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business