Form 6554 5/10 - Claim Form For Accident Policy (Page 2 of 2) in pdf

Claim Form for Accident Policy

Authorization

For the Use and Disclosure of Protected Health Information

I authorize the use and/or disclosure of my protected health information as described below:

1. My authorization applies to that information obtained by all health care professionals. This information may include my medical

records, laboratory reports, prescription medication records, and radiology reports in the possession of all health care professionals.

Only this information may be used and/or disclosed pursuant to this Authorization.

2. I authorize all health care professionals to disclose my protected health information.

3. I authorize only designated staff of Kanawha HealthCare Solutions, Inc., a Humana Company to receive, in writing, by photocopy,

facsimile, or by telephone, my protected health information.

4. I understand that, if my protected health information is disclosed to someone who is not required to comply with federal privacy

protection regulations, such information may be redisclosed and would no longer be protected.

5. I understand that I have a right to revoke this Authorization at any time. My revocation must be in writing in a letter addressed to

Kanawha HealthCare Solutions, Inc., P.O. Box 610, Lancaster, SC 29721. This revocation shall become effective on the date it is

received by Kanawha HealthCare Solutions, Inc. I am aware that my revocation is not effective to the extent that the persons I have

authorized to use and/or disclose my protected health information have acted in reliance upon this Authorization.

6. This Authorization is valid for twelve (12) months from the date of execution hereof.

I certify that I have received a copy of this Authorization and authorize the use and/or disclosure of my protected

health information as contemplated herein.

___________________________________________

_________________________________________

_____________

Signature

Printed Name

Date

I have legal authority* under the laws of the State of ____________________________ to make health care decisions on behalf of

__________________________________, the individual to whom the use and/or disclosure of protected health information

above applies, and execute this Authorization in my capacity as Authorized Representative thereof.

___________________________________________

_________________________________________

_____________

Name of Authorized Representative/Parent or Guardian

Relationship to Applicant

Date

* A copy of the legal authority document must be on file with Kanawha HealthCare Solutions, Inc.

6554 5/10

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Form 6554 5/10 - Claim Form For Accident Policy Page 2