Please fill out and return this HIPPA Compliant Authorization form along with your application.
We cannot begin to process your application until we receive the signed HIPAA form.
HIPAA Compliant Authorization for Release of Medical Information
ADA No. 161920311
Name of Insured/Patient:
Date of Birth:
I authorize any health plan, physician, healthcare professional, hospital, clinic, laboratory, holders of
prescription information on me, including but not limited to, pharmacies, pharmacy benefits managers, and
insurers, medical facility, or other healthcare professional that has provided payment, treatment or services
to me or on my behalf within the past 10 years ("My Providers") to disclose my entire medical record,
prescription history, medications prescribed, eligibility, prescribing physician, pharmacy information,
insurance coverage information, and any other protected health information concerning me to
This includes information on the diagnosis of treatment of Human Immunodeficiency Virus (HIV) infection
and sexually transmitted
This also includes information on the diagnosis and treatment of mental
illness and the use of alcohol, drugs, and tobacco.
By my signature below, I acknowledge that any agreements I have made to restrict my protected health
information do not apply to this authorization, and I instruct any physician, healthcare professional,
hospital, clinic, medical facility, or other healthcare provider to release and disclose my entire medical
This protected health information is to be disclosed under this Authorization so that Great-West may
administer claims and determine or fulfill responsibility for coverage and provision of benefits, administer
coverage, and conduct other legally permissible activities that relate to any coverage I have or have applied
for with Great-West.
This authorization shall remain in force for 36 months following the date of my signature below, and a copy of
this authorization is as valid as the
I understand that I have the right to revoke this authorization in
writing, at any time, by providing written notification to the entity identified above. I understand that a
revocation is not effective to the extent that any of "My Providers" have already relied on this Authorization to
disclose information about me or to the extent that Great-West has a legal right to contest a claim under an
insurance policy or to contest the policy itself. I understand that any information that is disclosed pursuant to
this authorization is no longer covered by federal rules governing privacy and confidentiality of health
information, but will not be re-disclosed by Great-West, except as authorized by me or as required by law.
I understand that "My Providers" may not refuse to provide treatment or payment for healthcare services if I
refuse to sign this authorization, or otherwise condition my enrollment or eligibility for health benefits on my
signing this authorization. I further understand that if I refuse to sign this authorization to release my complete
medical record, Great-West may not be able to make any benefit payments. I understand that any authorized
representative or I will receive a copy of this authorization upon request.
Signature of Insured/Patient or Personal Representative
Description of Personal Representative's Authority or Relationship to