Form Teb-Adbltchome-072413 - Accelerated Death Benefit For Long Term Care Claim Form Page 4
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4Name of Insurance Company (select one):
Transamerica Life Insurance Company
Monumental Life Insurance Company
If no Company is selected, the appropriate box will be checked by the Administrative Office.
Administrative Office: P.O. Box 8043
Little Rock, Arkansas 72203-8043
AUTHORIZATION FOR THE RELEASE OF HEALTH INFORMATION
I hereby authorize the use or disclosure of health information about the Insured as described below and revoke any previous restrictions concerning
access to such information:
1.
Person(s) or group(s) of persons authorized to use and/or disclose the information: Any physician, medical practitioner, hospital, clinic,
pharmacy, long-term care facility, nursing home, assisted living facility, home health care entity, medical or medically-related facility, laboratory,
and insurance company (including the Company selected above), or other organization, institution or person having records or knowledge of the
Insured’s health.
2.
Person(s) or group(s) of persons authorized to collect or otherwise receive and use the information: the Company noted above, its
affiliates, its reinsurers, their agents or other representatives, and business associates.
3.
Description of the information that may be used or disclosed: This authorization relates to the release of any medical records necessary to
evaluate and determine the Insured’s eligibility for benefits, including, but not limited to, those containing diagnoses, treatments, prescription
drug information, alcohol or drug abuse information, or information regarding AIDS. Exception: psychotherapy notes require a separate
signed authorization.
4.
The information will be used or disclosed only for the following purpose(s): The requested information will be used for any claim
processing purposes, including but not limited to determining the Insured’s benefit eligibility and making benefit determinations.
STATEMENTS OF UNDERSTANDING & ACKNOWLEDGMENT:
I understand that the Insured’s eligibility for benefits may be affected if I refuse to sign this form. In that case, the Company may not be able to
determine if the Insured qualifies for benefits.
I understand that the Insured has a right to receive the HIPAA Notice of Health Information Privacy Practices that explains the Company’s
privacy practices (not applicable to life, accident or disability insurance policies).
I understand that if the organization authorized to receive the information is not a health plan or health care provider, the released information
may no longer be protected by federal privacy regulations.
I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it,
or to the extent that other law provides the Company with the right to contest a claim under the policy or the policy itself, by sending a written
revocation to the Company’s Privacy Official at the address at the top of this form. I also understand that the revocation of this authorization will
not affect uses and disclosures of my health information for purposes of treatment, payment or health care operations.
This authorization shall be valid for as long as claims continue under the policy, and I understand I am entitled to a signed copy.
A copy of this authorization will be considered as valid as the original.
I acknowledge that I have received a copy of this authorization.
Patient/Insured’s Name/Signature
Date
Patient/Insured’s
Patient/Insured’s SSN
Date of Birth
Patient/Insured’s Phone No.
Patient/Insured’s Address
Personal Representative’s
Personal Representative’s (if any) Name/Signature:
Phone No.
Personal Representative’s (if any) Address
Description of Personal Representative’s Authority or
Relationship to Patient/Insured
Policy or Contract Number
Claimants should retain a copy of this signed document for their records
TEB-ADBLTCHome-072413
Page 4 of 4
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