Fillable Colonial Life Health/wellness Screening Claim Form

Colonial Life | HEALTH/WELLNESS SCREENING | Fax: 1-800-880-9325 | Telephone: 1-800-325-4368

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 Life) 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 necessary

by Colonial Life 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 Life obtains pursuant to this authorization will be used for the purpose of evaluating

and administering my claim for benefits or for evaluating my eligibility for insurance. Some information once

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 Life will not re-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. This authorization may be revoked by me or my authorized representative at any time except to

the extent Colonial Life 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 Life may not be able to evaluate my claim

or eligibility for insurance. I may revoke this authorization by sending written notice to: Colonial Life & Accident

Insurance Company, Claims Department, P.O. Box 100195, Columbia, SC 29202-3195.

I may refuse to sign this form; however, Colonial Life may not be able to evaluate and administer my claim or

eligibility for insurance.

I am the individual to whom this authorization applies or that person’s legal guardian, power of attorney

designee, conservator, beneficiary or personal representative.

_____________________________________________________________________

______________________________________________

Signature

Date signed

(MM/DD/YYYY)

XXX-XX-

_____________________________________________________________________

_______________

____________________

Printed name of individual subject to this disclosure

Last four digits of SSN

Date of birth

(MM/DD/YYYY)

If applicable, I signed on behalf of the insured as ___________________________________ (indicate relationship). If legal guardian,

power of attorney designee, conservator, beneficiary or personal representative, please attach a copy of the document granting authority.

_______________________________________________

__________________________________________

______________________

Printed name of legal representative

Signature of legal representative

Date signed

(MM/DD/YYYY)

Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. |

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Colonial Life Health/wellness Screening Claim Form - 2015 Page 4

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