Form Glc-07172 - Authorization For Release Of Information
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AUTHORIZATION FOR RELEASE OF INFORMATION
1. I
authorize any physician, medical professional, pharmacist or other provider of health care services, hospital, clinic,
(the undersigned)
other medical or medically related facility; insurance or reinsurance company; government agency; department of labor; acquaintance;
group policyholder; employer; or policy or benefit plan administrator to release information from the records of:
: ______________________________________________________________________________________
Claimant/Patient Name
(Last)
(First)
(Middle)
Date of Birth: ______________________________________
Social Security Number: _________________________________
2. Information to be released:
• data or records regarding my medical history, treatment, prescriptions, consultations
[including medical and psychological reports,
records, charts, notes (excluding psychotherapy notes), x-rays, films or correspondence, and any medical condition I may now have or have had];
• any information regarding insurance coverage; and
• any information, data or records regarding my activities (including records relating to my Social Security, Workers’ Compensation,
Retirement Income, financial, earnings and employment history).
3. Information to be released to:
The Lincoln National Life Insurance Company
PO Box 2609
Omaha, NE 68103-2609
4. I understand the information obtained by use of this Authorization will be used by The Lincoln National Life Insurance Company
to evaluate my claim for disability benefits. The Company will only release such information:
(“Company”)
• to its reinsurer, or other persons or organizations performing business or legal services in connection with my claim(s); or
• to a vendor, approved by the company, which specializes in the application for Social Security Disability Benefits
• to vendors/consultants providing the claimant with wellness, disability or leave related services as part of an employer sponsored
benefit plan
• to the employer for self-insured disability plans; or
• as otherwise may be required by law or as I may further authorize.
I further understand that refusal to sign this Authorization may result in the denial of benefits.
5. I understand the information used or disclosed may be subject to re-disclosure by the recipient and may no longer be protected by the
federal HIPAA Privacy Rule. For Colorado claims, the disclosed information may not be redisclosed or reused by the recipient under
Colorado law.
6. I understand that I may revoke this Authorization in writing at any time, except to the extent:
1. the Company has taken action in reliance on this Authorization; or
2. the Company is using this Authorization in connection with a contestable claim.
If written revocation is not received, this Authorization will be considered valid for a period of time not to exceed 24 months from the
date of my signature below. To initiate revocation of this Authorization, direct all correspondence to the Company at the above address.
7. A photocopy of this Authorization is to be considered as valid as the original.
8. I understand I am entitled to receive a copy of this Authorization.
SIGNATURE: ___________________________________________________________
DATE: ___________________________
Claimant/legal representative (Nearest relative, legal guardian, or appointed representative to sign only if claimant/patient is a minor, legally incompetent,
or deceased.) Power of attorney or guardianship must be attached.
PRINT NAME: ___________________________________________________________
Relationship to Claimant/Patient of personal/legal representative signing for Claimant/Patient: ________________________________
ADDRESS: _________________________________________________________
PHONE NO: ___________________________
(Street)
_________________________________________________________
(City)
(State)
(Zip Code)
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