Request For Individual Cancer, Intensive Care Or Dread Disease Benefits Form Page 2
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4American Fidelity Assurance Company
Mail to: AWD Benefits Department
P.O. Box 268898 | Oklahoma City, OK 73126-8898
Toll Free Phone # 1-800-437-1011
Local Fax # (405)-523-5762
Toll Free Fax # 1-888-243-3453
American Fidelity Assurance Company
2000 N. Classen Boulevard
Oklahoma City, Oklahoma 73106
AUTHORIZATION TO DISCLOSE HEALTH INFORMATION PROTECTED FEDERAL LAW (HIPAA)
I hereby authorize the entities specified below to disclose any information about my health or the health of my minor dependents that
are included under the coverage, including my or my dependents’ entire medical record, except psychotherapy notes, to individuals
representing American Fidelity Assurance Company (AFAC) who are involved in determining whether I am eligible for benefits under
my insurance coverage. Those so authorized are: a) licensed physicians or medical practitioners; b) hospitals, clinics or medically-
related facilities; c) health plans; d) Veteran’s Administration; e) past or present employers; f) consumer reporting agencies; g) insurance
companies; h) the Medical Information Bureau (MIB); and i) Department of Motor Vehicles.
NOTICE: Information authorized for release may include information on communicable or venereal diseases such as hepatitis,
syphilis, gonorrhea, HIV/AIDS (Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome) or other conditions for
which you may have been treated.
I understand that I may refuse to sign this authorization; however, if I do not sign the authorization, my failure to sign the
authorization may result in a denial or a delay of benefits. I understand that I may revoke this authorization at any time by writing
to AWD Benefits Department, American Fidelity Assurance Company, PO Box 268898, 2000 N. Classen Boulevard, Oklahoma City,
Oklahoma 73126, or by calling, toll-free, 1-800-437-1011. I understand that my right to revoke this authorization is limited to the extent
that: AFAC has taken action in reliance on the authorization; or, the law provides AFAC with the right to contest my insurance coverage or
a claim under my insurance coverage.
I understand that if protected health information is disclosed, the information may be redisclosed only in accordance with any other state
or federal regulations.
For health insurance coverage this authorization will expire twenty-four months from the date it is signed or upon termination of my
insurance policy, whichever occurs first. For insurance coverage other than health insurance, this authorization will expire twenty-four
months from the date it is signed or upon expiration of my claim for benefits, whichever occurs first. For Arizona residents, release of HIV/
AIDS-related information can only be disclosed for a period not to exceed 180 days from the date shown below
A copy of this authorization will be as valid as the original. I am aware that I, or my personal representative, am entitled to and will receive
a copy of this authorization.
AFA Account#
Printed Name
Date of Birth
Signature (Patient) or Personal
Date
Representative (if applicable)
Relationship of Personal Representative
If authorization is supplied by a personal representative, a description
to Representative to Patient
of the authority to act on behalf of the Insured must be included.
Please retain a copy for your personal records, or you may request a copy from our Company.
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