Authorization To Use And/or Disclose Personal Health Plan Page 2
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2Authorization to Use and/or Disclose Personal Health Plan
Information
Form Received By
Date
1. Employee Name
1a. Employee Health Plan ID Number
1b. Employee Date of Birth
2. Name of Person Whose Health Information is the Subject
2a. Relationship to Employee
of this Authorization
Self
Spouse
Child
Other
3. Your Name
3a. Authority
If you are not the person in Box 2, please describe your
authority to act on his or her behalf:
____________________________________________________________
4. Mailing Address for Records
4a. City, State, Zip Code
I hereby authorize ______________________________[Insert name of insurance carrier or HMO] on behalf of the group health plan
(“Plan”) sponsored by Loyola Marymount University to use and/or disclose the health information described in Sections A — E below.
Section A: Health Information to be Used and/or Disclosed.
Specify the health information to be released and/or used, including (if applicable) the time period(s) to which the information relates. Select only
one (1) of the following boxes:
All of my past, present or future health claims and/or medical records.
All of my health information relating to Claim Number ________________.
Other (please specify). ___________________________________________________________________________________________
Section B: Person(s) Authorized to Use and/or Receive Information.
Specify the persons or class of persons authorized to use and/or receive the health information described in Section A:
___________________________________________________________________________________________
Section C: Purposes for Which Information will be Used or Disclosed.
Specify each purpose for which the health information described in Section A may be used or disclosed. Select all of the applicable boxes
below:
To facilitate the resolution of a claim dispute.
As part of my application for leave of under the Family and Medical Leave Act (FMLA) or state family leave laws.
For a disability coverage determination.
At my request.
Other (please specify) ________________________________________________________________________________________
Section D: Expiration of Authorization
Specify when this Authorization expires. (Provide a date or triggering event related to the use or disclosure of the information.)
On the following date: _____________________.
Upon the passage of the following amount of time: _____________________________.
Upon my disenrollment from the group health plan sponsored by Loyola Marymount University.
Upon my return from FMLA leave.
Other (please specify)
Your rights:
•
You can revoke this Authorization at any time by submitting a written revocation to the Benefits Manager the following address: LMU
Benefits, Loyola Marymount University, University Hall, Suite 1900, One LMU Drive, Los Angeles, California 90045-2659.
•
A revocation will not apply to information that has already been used or disclosed in reliance on the Authorization.
•
Once the information is disclosed pursuant to this Authorization, it may be redisclosed by the recipient and the information will no longer be
protected by HIPAA.
•
The Plan may not condition Treatment, Payment, enrollment or eligibility for benefits on whether I sign the Authorization.
•
You will be provided with a copy of this Authorization Form, after signing, if the Plan sought the Authorization.
Signature of Participant & Date
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Parent category: Medical