Complaint Form - The Guardian Life Insurance Company Page 2
ADVERTISEMENT
1
2To:
Dental Office:
__________________________________
Address:
__________________________________
City:
__________________________________
State:
__________________________________
RE:
AUTHORIZATION TO RELEASE INFORMATION
You are hereby authorized to release to The Guardian Life Insurance Company if America (“Guardian”)
and its representatives any and all information you may have concerning my dental condition, including x-
rays, which you have obtained as a result of history, examination, testing, diagnosis, treatment
recommendations and/or treatment.
Guardian requires this information for the purpose of resolving my written complaint.
This Authorization shall remain valid for one year from today’s date. A signed copy of this Authorization
is as valid as the original.
I realize that I am entitled to have a copy of this signed Authorization and if one is requested, do
acknowledge receipt thereof.
Select ONE of the following options:
[ ] Guardian MAY provide the dentist(s) that is/are subject of this complaint a copy of
my written complaint.
[ ] Guardian MAY NOT provide the dentist(s) that is/are subject of this complaint a copy
of my written complaint.
If no choice is indicated, Guardian will understand that authorization to release a copy of
this complaint is approved.
I have read this Authorization before signing it.
______________________________________
_________________________________
Signature
Type or Print Name
______________________________________
______________________________
Member ID Number
Date
If not signed by the patient, please indicate relationship:
[ ] Parent or guardian of minor patient
[ ] Guardian or conservator of incompetent patient
[ ] Beneficiary or personal representative of deceased patient
[ ] Spouse or person financially responsible for the patient, where the dental information is being sought
for the sole purpose of processing an application for health insurance or for enrollment in a nonprofit
hospital plan, a health care service plan, or an employee benefit plan, and where the patient is to be an
enrolled spouse or dependent under the policy or plan.
The Guardian Life Insurance Company of America P.O. Box 4391, Woodland Hills, CA 91365-4391
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business