Form Hwm-F023 - Authorization Form

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SOUTHERN CALIFORNIA PIPE TRADES
HWM-F023
(rev060208)
HEALTH & WELFARE FUND
.
.
.
.
th
501 Shatto Place, 5
Floor
Los Angeles, CA 90020
(800) 595-7473
(213) 385-6161
Fax: (213) 383-0725
AUTHORIZATION FORM
PURPOSE OF FORM
PATIENT INFORMATION
NAME:
__________________________
In order for the Southern California Pipe Trades Health &
Welfare (“Fund”) to use or disclose your Protected Health
Information to someone other than you, you must complete
STREET: __________________________
this Authorization Form and return it to the Fund.
CITY:
__________________________
Protected Health Information (“PHI”) is information that is
created, received, transmitted or stored by the Fund which
relates to your past, present, or future physical or mental
ZIP & STATE:
____________________
health, health care, or payment for health care, and either
identifies you or provides a reasonable basis for identifying
SSN:
________-________-_________
you. Except as permitted by law, the Fund may not use or
disclose PHI to persons other than those you specify on this
form.
Are you a dependent?
YES
NO
The Fund may request that you complete this form where the
If YES, please state:
use or disclosure of information is necessary to carry out
functions of the Fund. In addition, you may submit this form
Relationship to member: _______________________
to the Fund because you want someone to request or receive
your PHI from the Fund. This form is not needed if you are
Member’s Name: _____________________________
requesting your own PHI from the Fund.
Member’s SSN:
_______________________________
PART I: Authorized Person
I authorize the Fund to disclose my protected health information (PHI) identified in Part II of this form to the following person.
(Please designate no more than one person and provide their name and address. If you want different individuals to have access to different
information, please fill out separate forms for each individual.)
FIRST
Middle Initial
LAST
STREET
CITY
STATE
ZIP
___
_____
RELATIONSHIP:
SPOUSE
FAMILY
OTHER:
PART II: Effective Period of the Form
This Authorization Form is valid for the period designated below:
For as long as I am eligible for benefits
Until
under the Plan;
(please provide date or event);
Until I cancel by submitting a Cancellation
of Authorization Form.
(You may also cancel this authorization at any time, no matter which option you select above, by submitting to the Fund Office a
properly completed Cancellation of Authorization Form.)

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