Fillable Release Of Health-Related Information Form printable pdf download

RELEASE OF HEALTH-RELATED INFORMATION

Banner Life Insurance Company

3275 Bennett Creek Avenue

Frederick, Maryland 21704

Health

Although the application you completed includes a disclosure authorization, as a result of recent changes in the federal

Insurance Portability and Accountability Act (HIPAA)

, your medical provider may ask for this HIPAA specific form.

THIS AUTHORIZATION COMPLIES WITH THE HIPAA PRIVACY RULE

Print Name of Proposed Insured / Patient

Date of Birth

Print Name of Person or Organization Providing Information

AUTHORIZATION

I authorize any physician, health plan, medical practitioner, medical care provider, psychologist, chiropractor, physical therapist,

hospital, nursing home, mental health facility, rehabilitation or ambulatory care center, medical clinic, laboratory, pharmacy,

treatment facility, or other medical or medically related facility, specifically including those persons/organizations listed above, to

give or disclose my entire medical record and any other protected health information concerning me for the past 10 years to Banner

Life Insurance Company, its agents, employees, vendors or representatives. Any and all records and information regarding

diagnosis, testing, treatment, and prognosis of my physical or mental condition are to be released. This includes information on

the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This also includes

information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco.

This protected health information is to be disclosed under this authorization so that Banner Life Insurance Company may: 1)

underwrite my application for coverage, make eligibility, risk rating, and policy issuance determinations; 2) obtain reinsurance;

3) administer claims and determine or fulfill responsibility for coverage and provision of benefits; 4) administer coverage; and 5)

conduct other legally permissible activities that relate to any coverage I have or have applied for with Banner Life Insurance

Company.

By signing below, I terminate any agreements I have made to restrict my protected health information and I instruct any physician,

health care professional, hospital, clinic, medical facility or other health care provider to release and disclose my entire medical

record without restriction.

This authorization shall be valid for two (2) years after the date on which it is signed by me, and a copy of this authorization is

as valid as the original.

I understand that I have the right to revoke this authorization in writing, at any time, by sending a written request for revocation to

the Company at 3275 Bennett Creek Avenue, Frederick, Maryland 21704, Attention: Privacy Official. I understand that a revocation

is not effective if any of My Providers has relied on this authorization or to the extent that the Company has a legal right to contest

a claim under an insurance policy or to contest the policy itself. I understand that any information that is disclosed pursuant to

this authorization may be redisclosed and no longer covered by certain federal rules governing privacy and confidentiality of

health information.

I understand that My Providers may not refuse to provide treatment or payment for health care services if I refuse to sign this

authorization. I further understand that if I refuse to sign this authorization, the Company may not be able to process my application,

or if coverage has been issued may not be able to make any benefit payments.

I understand and acknowledge that I will receive or have received a copy of this authorization.

Signature of Proposed Insured / Patient

Date (required)

Social Security Number of Proposed Insured

Agent or Witness Signature

LU-1250 (9/03)

Release Of Health-Related Information Form

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