Authorization To Use & Disclose Health Information
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1Premier Access Insurance Company
P.O. Box 659010
Sacramento, CA 95865-9010
Dental and Vision
AUTHORIZATION TO USE & DISCLOSE HEALTH INFORMATION
Name of Member:____________________________________________ I.D. Number: ____________________________
Address of Member: _________________________________________________________________________________
I authorize Premier Access Insurance Company to use and disclose a copy of the specific health and dental information
described below.
Information consisting of: (Check all that apply.)
Eligibility
Benefits
Claims
Prior Authorizations/Specialty Referrals
Other (Please specify)
_______________________________________________________________________
Name of the Person(s) or Organization(s) to whom you authorize us to use or disclose your information:
Please check all that apply, and list the name or organization:
______________________________________
____________________________________
Spouse
Mother
Employer
_____________________________________
Father
____________________________________
________________________________________
_____________________________________
Child
Other
For the purpose of: (Describe intended use or purpose of this disclosure)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Expiration of Authorization: (For how long do you wish this Authorization to last)
____________________________________
1 year
3 years
5 years
No expiration
Other
If we are requesting this Authorization from you for our own use and disclosure or to allow another health care provider or
health plan to disclose information to us:
•
We cannot condition our provision of services or treatment to you on the receipt of this signed authorization;
•
You may inspect a copy of the protected health information to be used or disclosed;
•
You may refuse to sign this Authorization; and
•
We must provide you with a copy of the signed authorization.
You have the right to revoke this Authorization at any time, provided that you do so in writing and except to the extent that
we have already used or disclosed the information in reliance on this Authorization.
Unless revoked earlier or otherwise indicated, this Authorization will expire one year from the date of signing or shall remain
in effect for the period reasonably needed to complete the request.
I have reviewed and I understand this Authorization. I also understand that the information used or disclosed pursuant
to this Authorization may be subject to re-disclosure by the recipient and no longer be protected under federal law.
By:___________________________________________________________ Date: __________________________
Signature of Member (or authorized representative, if Member is a minor)
Printed Name of Authorized Representative _______________________________________________________
Relationship to Member _______________________________________________________________________
Please mail this form to the above-mentioned address to the attention of Customer Service. You may also FAX the form
to 916.646.9000 to the Attention of Customer Service.
FOR INTERNAL USE ONLY
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HIPAA AUTH – PA (01/12)
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