Authorized Representative Form - Public Employee Benefit Authority

SOUTH CAROLINA PUBLIC EMPLOYEE BENEFIT AUTHORITY

AUTHORIZED REPRESENTATIVE FORM

Note: This form is used to confirm permission for the health plan to discuss or disclose a subscriber’s Protected Health

Information to a particular person who acts as the subscriber’s Authorized Representative. Use of this information is

strictly limited to that purpose described herein.

REQUESTOR’S INFORMATION

By signing this form, I understand and agree that South Carolina Public Employee Benefit Authority (PEBA) Insurance

Benefits may release my personal health information, defined as, but not limited to, identification of treating providers of

care, personal diagnoses, procedures and demographic information (but not including any psychotherapy notes). I

understand that this authorization does not provide my Authorized Representative with any authority, either implied or

direct, over any treatment or direct-care decisions. I also understand that executing this form will not alter the manner in

which PEBA processes my benefits payments, enrollment/change forms or my eligibility for benefits.

Requestor’s Name: __________________________________ Benefits Identification Number:_____________________

Address: _________________________________________________________________________________________

Telephone Number: ___________________________ Email Address: _______________________________________

Policyholder’s Name (if different from above): ____________________________________________________________

Policyholder’s SSN (if different from above): _____________________________________________________________

AUTHORIZED USE AND/OR DISCLOSURE

Intended Use or Disclosure:

I understand that PEBA’s general policy is not to disclose my personal health information to other parties, except those

directly involved in my care, without my written authorization or as permitted or required by law. For this reason, I

authorize PEBA to discuss and disclose my personal health information to the person(s) named below for the purpose of

assisting with, or facilitating, the coordination or payment of my health plan benefits. I also understand that if my

Authorized Representative is not a health care provider or another entity subject to federal or applicable state privacy

laws, my personal health information may no longer be protected by those privacy laws and that my Authorized

Representative may further disclose my personal health information without my authorization. I acknowledge that my

authorization is voluntary.

Authorized Representative #1:

Name: _______________________________________________ Phone Number: ______________________________

Address:_________________________________________________________________________________________

Relationship to You: ________________________________________________________________________________

Authorized Representative #2:

Name: _______________________________________________ Phone Number: ______________________________

Address:_________________________________________________________________________________________

Relationship to You: ________________________________________________________________________________

Rev. September 2014

Authorized Representative Form - Public Employee Benefit Authority - South Carolina