Fillable Request For Accident Only Policy Benefits Form (Page 2 of 4) in pdf

American 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

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

I hereby authorize the entities specified below to disclose any information about me or my dependents’ health including my or

my dependents’ 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 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) 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 you 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 you may have been treated. This authorization excludes disclosure of the result of a

test for HIV if you have tested HIV positive but have 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 you have

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, P.O. 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 my insurance coverage or a claim under my 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.

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.

AFA Account#

Printed Name

Date of Birth

Signature (Patient) or Personal

Date

Representative (if applicable)

If authorization is supplied by a personal representative, a description

Relationship of Personal Representative

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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BN-713-AWD-1011

Request For Accident Only Policy Benefits Form Page 2

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