Hospital 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. This includes information on

the diagnosis or treatment of Human Immunodeficiency virus (HIV) 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, 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,

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

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 I have or have applied for with Great-West.

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. I understand that I have the right to

revoke this authorization in writing, at any time, by providing written notification to the entity

identified above, I 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 has a legal right to contest a claim under an insurance policy or to

contest the policy itself. I 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. I further understand that if I refuse to sign

this authorization to release my complete medical record, Great-West may not be able to make

any benefit payments. I understand that any authorized representative or I 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

M 4022 (09/11)

1 B

Hospital Coverage Claim Report Form Page 2