Form Gc-014372-Wro - Authorization To Disclose Health Information printable pdf download

Authorization to

Disclose Health Information

Member Information:

(Individual whose information will be released)

Name: ____________________________________________________________ Date of Birth: ___________________

(First, Middle, Last)

(Month/Day/Year)

Address: _________________________________________________________________________________________

City

State

Zip Code

Telephone Number: _________________________________

(including area code)

Employer Name: _____________________________________________________ Group Plan #: _________________

Employee Name: __________________________________________ Social Security Number: ____________________

I authorize the use or disclosure of personal and health information by Guardian, as described below:

Any and all health information in the possession of Guardian.

Claim information regarding treatment for the following condition or injury ____________________________________

___________________________________________ on or about _________________________________________

Health information covering the period of time ___________________________ to ____________________________

Other (Please specify and include dates) _____________________________________________________________

______________________________________________________________________________________________

This information may be disclosed to, and used by, the following individuals or organizations:

Name: __________________________________________________________ Relationship______________________

Address: _________________________________________________________________________________________

City: ___________________________________________________________ State: ____________ Zip: ____________

Name: ___________________________________________________________ Relationship_____________________

Address: _________________________________________________________________________________________

City: ___________________________________________________________ State: ____________ Zip: ____________

This information is being disclosed for the following purpose(s):

_________________________________________________________________________________________________

I understand that I have the right to revoke this authorization at any time. I understand that in order to revoke this authorization, I must do so in

writing and send my written revocation to Guardian at the address below. I understand that the revocation will not apply to information that has

already been released in response to this authorization. I understand that the revocation will not apply to Guardian when the law provides it with the

right to contest a claim under my group plan. Unless otherwise revoked, this authorization will expire within thirty (30) months of the signature date.

I understand that I do not have to sign this authorization and that Guardian may not condition treatment or payment on whether I sign this

authorization.

I understand that once the information is disclosed pursuant to this authorization, it may be redisclosed by the recipient and the information may not

be protected by federal privacy regulations.

Print Name: ___________________________________________________

Relationship: _______________________

Signature: ____________________________________________________

Date: __________________________

Note that no authorization to disclose health information will be processed

unless you or your authorized representative have signed this form.

If you are an authorized representative (other than a parent of a minor child), you will need to provide documentation or an

explanation of your authority to act for the member (e.g., Power of Attorney).

Please send this form to:

The Guardian Life Insurance

Company of America