Initial Credit/closed End Monthly Outstanding Balance Disability Claim Form Page 4
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4American Bankers Life Assurance Company of Florida
Time Insurance Company
P.O. Box 977122, Miami, FL 33197-7122
1.800.327.5288
Fax 305.252.6910
Attn: DFS Claims Department
Authorization for Release of Protected Health Information
The Health Insurance Portability and Accountability Act (HIPAA) requires us to get your written permission to obtain specific
health information about you. We are requesting this information in order to process the claim you are presenting to our company.
Therefore, please complete in detail, sign, date, and return the following form to us. We cannot process your claim until we have
this form returned to us.
I UNDERSTAND THAT THIS AUTHORIZATION IS VOLUNTARY
I hereby authorize the medical providers listed below to release the following information.
INSURED INFORMATION
NAME
SOCIAL SECURITY NUMBER
BIRTH DATE
DAYTIME TELEPHONE NUMBER
-
-
(
)
/
/
STREET ADDRESS
CITY
STATE
ZIP CODE
MEDICAL PROVIDER (doctor, hospital, etc.) WHO I AUTHORIZE TO RELEASE MY PERSONAL INFORMATION:
NAME
TELEPHONE NUMBER
(
)
STREET ADDRESS
CITY
STATE
ZIP CODE
DESCRIPTION OF INFORMATION TO BE RELEASED
ENTIRE MEDICAL RECORD
HIV/AIDS TEST RESULTS OR DIAGNOSIS AND TREATMENT
Yes
No
Yes
No
OTHER
I UNDERSTAND THAT:
a.
This Authorization may be revoked by me at any time by writing to the company and clearly stating that I wish to revoke
this Authorization.
b.
1.
This Authorization will expire without any action by me one year after the date of my signing below.
2.
This Authorization shall be valid for the duration of the claim (Arizona residents only).
c.
Revocation will not apply to my insurance company when the law provides my insurance company the right to contest a
claim under my policy.
d.
This authorization is voluntary and I have the right to refuse to sign it.
e.
If I revoke this information, it will not apply to information that has already been released prior to my revocation.
f.
Information released by this authorization may include information concerning treatment of physical and mental illness,
alcohol/drug abuse and past medical history.
g.
Information released by this authorization may be subject to redisclosure by the recipient and may not be protected any
longer by the HIPAA Privacy Rule.
h.
I agree that a photocopy of this authorization shall be as valid as the original.
i.
I, or my authorized representative, have the right to receive a copy of this authorization.
YOUR SIGNATURE (INSURED OR LEGAL REPRESENTATIVE)
DATE
X
/
/
AND if signing on behalf of a minor or as legal representative of another:
NAME OF PERSON YOU ARE SIGNING FOR (PROOF OF YOUR AUTHORIZATION MAY BE REQUIRED)
ONE FORM MUST BE COMPLETED FOR EACH MEDICAL PROVIDER
Please photocopy this form if you need additional copies.
C1030-0412
Page 4 of 4
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