State Employees' Supplemental Coverage Plan Form - 2006

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1/06
STATE EMPLOYEES’ SUPPLEMENTAL COVERAGE PLAN
AUTHORIZATION FOR DISCLOSURE
OF PROTECTED HEALTH INFORMATION
This authorization will permit the State Employees’ Insurance Board (SEIB) to disclose your health information that
you describe below (“Protected Health Information”) to the persons or entities and for the purpose that you
describe below. Please read and complete the following, and return to State Employees’ Insurance Board,
P O Box 304900, Montgomery, Alabama 36130-4900.
A. The Individual Who is The Subject of the Protected Health Information.
NOTE: A separate authorization form must be completed by each individual (or hi/her personal representative) who desires
to request that the SEIB disclose his/her Protected Health Information as described in this authorization.
Name
Date of Birth
Contract Number (as it
Social Security Number
MM/DD/YYYY
appears on your Health Plan
ID Card)
Address
Telephone Number
B. Description of My Protected Health Information To Be Disclosed.
Note: Please insert your initials in front of the paragraph below (1, 2 or 3) that applies to the description of your Protected Health
Information to be disclosed pursuant to this authorization. If you initial paragraph 2 or 3, please complete the blanks below that paragraph.
1. ________ Any or all of my Protected Health Information that may be requested from time to time by the person(s) I identify in Section D
below.
2. ________ All my Protected Health Information related to one or more of the following:
Description of Claim __________________________________________________________________________________________________
Timeframe(s) of Service _______________________________________________________________________________________________
Name of Provider ____________________________________________________________________________________________________
3. ________ Other. Here is a specific description of my Protected Health Information to be disclosed.
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
C. Person(s) Authorized To Disclose My Protected Health Information.
By signing this authorization, I hereby authorize the SEIB to disclose my Protected Health Information.
D. Person(s) Authorized To Receive My Protected Health Information.
Name __________________________________________________________________________________________________
Address ________________________________________________________________________________________________
Telephone ______________________________________________________________________________________________

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