Member Requested Authorization for Release of Information
Please read these instructions carefully before completing this form.
When to Use This
You must complete this form if you want SelectAccount to give information
about you to someone else (for example: an agent or family member).
Parents or a legal guardian may sign for a minor unless the minor is
permitted under state law to consent to the treatment. In that case, the
minor must sign the authorization.
How to Complete
The Authorization for Release of Information form must be completed and
signed by one of the following:
♦ The person whose information will be released
♦ The parent or legal guardian of a minor whose information will be
released except as listed above
♦ The personal representative of the person whose information will be
released (e.g., power of attorney, conservator, legal guardian, executor)
To complete this form:
♦ Fill in the name, member identification and date of birth of the person
whose information will be released.
♦ Check the type(s) of information you want us to release.
♦ Fill in the name and address of the person or employer who will receive
♦ State the purpose for this authorization for release.
♦ Sign and date the form.
♦ If you are not the person whose record will be released, state your
relationship to that person
Mail or fax this
P.O. Box 64193
St. Paul, MN 55164-0193
Fax: 651-662-7247 or 1-866-231-0214