Statement Of Claimant For Life And/or Annuity Benefits Form (Page 2 of 2) in pdf

part Vii autHoriZation to uSe or diSCloSe proteCted HealtH information

i hereby authorize the entities specified below to disclose any information about the deceased’s health including the

deceased’s entire medical record and history of treatment for physical and/or emotional illness to include psychological

testing, except psychotherapy notes, to individuals representing american fidelity assurance Company (afaC) who are

involved in determining whether the deceased is eligible for benefits under this 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) pharmacy; g) insurance companies; h) the Social Security administration; i)

retirement systems; j) department of motor Vehicles, and k) Workers’ Compensation Carrier. Colorado state law prohibits the

redisclosure or reuse of information disclosed about a Colorado resident under this authorization.

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 the deceased may have been treated. for maine residents, information authorized for release may include information

on communicable or venereal diseases such as hepatitis, syphilis, gonorrhea, aidS/arC (acquired immune deficiency

Syndrome /aidS related Complex) or other conditions for which the deceased may have been treated. this authorization

excludes disclosure of the result of a test for HiV if the deceased has tested HiV positive but has not developed symptoms of

the disease aidS. Such test results shall not be discovered or published. nothing in this caveat will prohibit this authorization

from including the fact that the deceased had aidS. for Vermont residents, this authorization does not require disclosure of

prior HiV-related tests. for Wisconsin residents, results of aidS/HiV test do not need to be reported if they were done at any

anonymous counseling and testing site, if the test was not an fda-licensed blood test, or through the use of a home test kit. 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.

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, po box 268898, oklahoma City, oK 73126-8898 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 the deceased’s insurance coverage or a claim

under the deceased’s insurance coverage. a copy of this authorization will be as valid as the original.

i understand that if protected health information is disclosed to a person or organization that is not required to comply with

federal privacy regulations, the information may be redisclosed and no longer protected by the federal privacy regulations.

this authorization will expire twenty-four months from the date it is signed or upon expiration of my claim for benefits,

whichever occurs first.

Signature of personal representative/beneficiary

printed name (deceased)

date of birth (deceased)

relationship to deceased

afa account#

date

If authorization is supplied by a personal representative, a description 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.

BN-151(AWD)(FL)-0609

Statement Of Claimant For Life And/or Annuity Benefits Form Page 2