Health Republic Nj Hippa Authorization Form (Page 2 of 2) in pdf

Health Republic Nj Hippa Authorization Form Page 2

Please print member’s name and address (Street Address, City, State and Zip Code)

______________________________________________________________________________



Check here if you are signing as a personal representative and complete information below.

Please attach the appropriate documentation (i.e. Power of Attorney). This only applies if

someone other than the member signed above.

Print the Personal Representative’s address (Street Address, City, State and Zip Code)

______________________________________________________________________________

Telephone number for Personal Representative: ______________________________________

Relationship to Member: _________________________________________________________

All information provided will be validated by HRINY

Note: To remove or change a disclosure authorization on file please contact Member Services

at 888 990 5702 Monday through Friday 8:30 AM-5:30 PM

Please submit this form by fax or mail

Fax: 1-646-924-3707

Mailing Address:

Health Republic Insurance of New York Member Service Team

30 Broad Street 34

Floor

New York, NY 10004

HRINY_RC04_PHI_Release form V1

Health Republic Nj Hippa Authorization Form Page 2