Critical Condition Coverage Claim Report Form (Page 2 of 2) in pdf

HIPAA Compliant Authorization for Release of Medical Information

______________________________________________________________

_______/_______/_______

Name of insured/patient (please type or print)

Date of Birth

I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, holders of

prescription information on me, including but not limited to, pharmacies, pharmacy benefits managers, and

insurers, medical facility, or other health care professional that has provided payment, treatment or services to

me or on my behalf within the past 10 years (“My Providers”) to disclose my entire medical record, prescription

history, medications prescribed, eligibility, prescribing physician, pharmacy information, insurance coverage

information and any other protected health information concerning me to Great-West Life & Annuity Insurance

Company. This includes information on the diagnosis or treatment of Human lmmunodeficiency virus (HlV)

infection and sexually transmitted diseases. This also includes information on the diagnosis and treatment of

mental illness and the use of alcohol, drugs and tobacco.

By my signature below, l acknowledge that any agreements l have made to restrict my protected health

information do not apply to this authorization and l instruct any physician, healthcare professional, hospital,

clinic, medical facility, or other health care provider to release and disclose my entire medical record without

restriction.

This protected health information is to be disclosed under this Authorization so that Great-West Life & Annuity

Insurance Company may administer claims and determine or fulfill responsibility for coverage and provision of

benefits; administer coverage; and conduct other legally permissible activities that relate to any coverage l

have or have applied for with Great-West Life & Annuity Insurance Company.

This authorization shall remain in force for 36 months following the date of my signature below and a copy of

this authorization is a valid as the original. l understand that l have the right to revoke this authorization in

writing, at any time, by providing written notification to the entity identified above, l understand that a revocation

is not effective to the extent that any of “My Providers” have already relied on this Authorization to disclose

information about me or to the extent that Great-West Life & Annuity Insurance Company has a legal right to

contest a claim under an insurance policy or to contest the policy itself. l understand that any information that is

disclosed pursuant to this authorization is no longer covered by federal rules governing privacy and

confidentiality of health information, but will not be redisclosed by (the recipient) except as authorized by me or

as required by law.

I understand that “My Providers” may not refuse to provide treatment or payment for health care services if I

refuse to sign this authorization, or otherwise condition my enrollment or eligibility for health benefits on my

signing this authorization. l further understand that if l refuse to sign this authorization to release my complete

medical record, Great-West Life & Annuity Insurance Company may not be able to make any benefit

payments. l understand that any authorized representative or l will receive a copy of this authorization upon

request.

Signature of Insured/Patient or Personal Representative

Date

Description of Personal Representative’s Authority or Relationship to Patient

M4738 (REV. 09/11)

Critical Condition Coverage Claim Report Form Page 2