State Employees' Supplemental Coverage Plan Form

E. Purpose of This Disclosure of My Protected Health Information (select one).

At my request

Other (please specify) _________________________________________

F. Date of Expiration of this Authorization (select one).

Until my coverage under my Health Plan (identified by the Contract Number on front) terminates.

Expiration Date ___________________________________ If no expiration date is indicated, this authorization

will expire in 90 days from the date of this authorization.

G. Right to Revoke this Authorization.

I understand that I may revoke this authorization at any time by giving written notice of my revocation to the address listed below. I

understand that revocation of this authorization will not affect any action taken in reliance on this authorization before you received

my written notice of revocation.

STATE EMPLOYEES’ INSURANCE BOARD

ATTENTION: PRIVACY OFFICIAL

P O BOX 304900

MONTGOMERY, ALABAMA 36130-4900

H. Signature:

By signing this authorization, I understand that my Protected Health Information described herein may be redisclosed by

the person(s) I have authorized to receive and use my Protected Health Information and that my Protected Health

Information described herein may no longer be protected by federal privacy laws.

I, __________________________________________________, have had full opportunity to read and consider the contents

of this authorization.

Signature ______________________________________________________________ Date ___________________________

*Personal Representative Signature ________________________________________ Date ___________________________

*If signed as a Personal Representative, you must describe your authority to act as the Personal Representative of the individual

who is the subject of the Protected Health Information described in this authorization (“Individual”) by initialing one of the

following:

__________ The individual is an unemancipated minor child, I am the parent and have authority under applicable law to act on

behalf of the individual in making decisions related to health care, and the health information described herein is relevant to my

personal representation of the individual. Please note: You should consult your state’s laws to find out if you have legal

authority to make health care decisions for your child. If you are unsure whether you have such legal authority, both you

and your child must sign this authorization.

__________ The individual is an adult, unemancipated minor or emancipated minor, I am the guardian, attorney-in-fact or other

authorized representative and have authority under applicable law to act on behalf of the individual in making decisions related to

health care, and the health information described herein is relevant to my personal representation of the individual. Attached is a

copy of the legal document(s) that give me authority to act as a Personal Representative, such as letters of guardianship.

__________ The individual is deceased, I am the executor, administrator or other person authorized under applicable laws to act

on behalf of the individual’s estate, and the health information described herein is relevant to my personal representation of the

individual or the individual’s estate. Attached is a copy of the legal document(s) that give me authority to act as a Personal

Representative, such as letters testamentary or letters of administration.

PLEASE RETAIN A COPY OF THIS AUTHORIZATION FOR YOUR RECORDS AFTER YOU SIGN IT.

State Employees' Supplemental Coverage Plan Form - 2006 Page 2