Form 74606-6 - Colonial Life & Accident - Group Supplemental Indemnity Claim Form Page 4

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Phone 1.800.325.4368

Fax 1.800.880.9325

Authorization for Colonial Life & Accident Insurance Company

For the purpose of evaluating my eligibility for insurance and eligibility for benefits under an existing

policy/certificate including checking for and resolving any issues that may arise regarding incomplete or

incorrect information on my application or claim forms, I hereby authorize the disclosure of the following

information about me and, if applicable, my dependents, from the sources listed below to Colonial Life &

Accident Insurance Company (Colonial Life) and its duly authorized representatives.

Health information may be disclosed by any health care provider or institution, health plan or health care

clearinghouse that has any records or knowledge about me including prescription drug database or

pharmacy benefit manager, or ambulance or other medical transport service. Health information may also

be disclosed by any insurance company, Medicare or Medicaid agencies or the Medical Information

Bureau (MIB). Health information includes my entire medical record and insurance claim history but does

not include psychotherapy notes. Non health information including earnings or employment history or any

other facts deemed appropriate by Colonial Life to evaluate my application or claim forms may be

disclosed by any entity, person or organization that has these records about me, including but not limited

to my employer, employer representative and compensation sources, insurance company, financial

institution or governmental entities including departments of public safety and motor vehicle departments.

Any information Colonial Life obtains pursuant to this authorization will be used for the purpose of

evaluating and administering my claim for benefits. Some information obtained may not be protected by

certain federal regulations governing the privacy of health information, but the information is protected by

state privacy laws and other applicable laws. Colonial Life will not re-disclose the information unless

permitted or required by those laws. Re-disclosed information may no longer be protected by federal

privacy laws. This authorization is valid for two (2) years from its execution or the duration of my claim,

whichever is earlier and a copy is as valid as the original. I know that I or my authorized representative

may request a copy of this authorization and access to this information. This authorization may be revoked

by me or my authorized representative at any time except to the extent Colonial Life has relied on the

authorization prior to notice of revocation or has a legal right to contest coverage under the contract or the

contract itself. If revoked, Colonial Life may not be able to evaluate my claim or eligibility for benefits. I

may revoke this authorization by sending written notice to: Colonial Life & Accident Insurance Company,

Claims Department, P. O Box 100195, Columbia, SC 29202-3195.

You may refuse to sign this form; however, Colonial Life may not be able to evaluate and administer your

claim. I am the individual to whom this authorization applies or that person’s legal Guardian, Power of

Attorney Designee, Conservator, Beneficiary or personal representative.

X________________________________

XXX-XX-_______________________

________________

(Signature)

(Social Security Number — last 4 digits)

(Date of Birth)

__________________________________________________ _____________________________

(Printed name of individual subject to this disclosure)

(Date Signed)

If applicable, I signed on behalf of the insured as ___________________________(indicate relationship).

If legal Guardian, Power of Attorney Designee, Conservator, Beneficiary or personal representative.

______________________________

___________________________

_____________

(Printed name of legal representative)

(Signature of legal representative)

(Date Signed)

7 4606-‐6

Colonial L ife p roduct a re u nderwritten b y C olonial L ife & A ccident i nsurance C ompany, f or w hich C olonial L ife i s t he m arketing b rand

08/13-‐Visit u s o nline a t C 4