Authorization Form For The Release Of Information - Unitedhealthcare Specialty Benefits, Maine

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AUTHORIZATION FOR RELEASE OF INFORMATION
TO BE COMPLETED BY EMPLOYEE
AUTHORIZATION
FOR THE RELEASE OF INFORMATION
HIPAA
Claimant's Name: |Claimant Name|
Claimant's Date of Birth: |Date of Birth|
I hereby authorize any physician, pharmacy, pharmacy benefit manager, psychologist,
medical practitioner, hospital, clinic, other medical or medically related facility, insurance or
reinsuring company, agent, Health Claims Index, employer, Medical information Bureau
(MIB), Social Security Administration, Government Agency or the Veterans Administration,
pharmacy benefit manager, hospital, insurance company, government agency or other entity
presented with a copy of this authorization, for furnish UnitedHealthcare Specialty Benefits
or their authorized representative, any and all information in their possession regarding my
treatment, medical history, benefits or other applicable information regarding my disability.
This includes, but is not limited to information concerning HIV, AIDS and mental health
information.
All information submitted shall be used in conjunction with the evaluation of my claim for
disability benefits. I understand that this authorization maybe withdrawn by me at any time
except to the extent that action has been taken in reliance upon it or as otherwise specified
by law. This authorization shall expire 18 months from the date it is signed unless I revoke it
in writing prior to that date by sending notice to the address show below. I understand that
one this information is received by the authorized person/organization, then this information
may be subject to redisclosure, and may no longer be protected by federal privacy laws. A
photocopy of this form will be as valid as the original.
Date: _______ /_______ / _______
Signature: _______________________
Address: _________________________________________________________
Phone: ( _______ ) ______ - __________
RETURN TO:
UnitedHealthcare Specialty Benefits
PO Box 7408
Portland, Maine 04112-7408
Phone 877-202-5300
Fax 888-505-8550

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