Fillable Routine Pregnancy Claim Form (Page 2 of 4) in pdf

American Fidelity Assurance Company

Mail to: AWD Benefits Department

P.O. Box 268898 | Oklahoma City, OK 73126-8898

toll Free Phone # 1-800-437-1011

toll Free Fax # 1-888-243-3453

AUthoriZAtioN to UsE or DisCLosE ProtECtED hEALth iNForMAtioN

I hereby authorize the entities specified below to disclose any information about my health or the health of my minor dependents that are included under

the coverage, including my or my dependents’ entire medical record, except psychotherapy notes, to individuals representing American Fidelity Assurance

Company (AFAC) who are involved in determining whether I am eligible for benefits under my insurance coverage. Those so authorized are: a) licensed

physicians or medical practitioners; b) hospitals, clinics or medically-related facilities; c) health plans; d) Veteran’s Administration; e) past or present

employers; f) consumer reporting agencies; g) insurance companies; h) the medical Information Bureau (mIB); and i) Department of motor Vehicles.

NotiCE: information authorized for release may include information on communicable or venereal diseases such as hepatitis, syphilis,

gonorrhea, hiV/AiDs (human immunodeficiency Virus/Acquired immune Deficiency syndrome) or other conditions for which you may have been

treated.

i understand that i may refuse to sign this authorization; however, if i do not sign the authorization, my failure to sign the authorization may result

in a denial or a delay of benefits. I understand that I may revoke this authorization at any time by writing to AWD Benefits Department, American Fidelity

Assurance Company, PO Box 268898, 2000 N. Classen Boulevard, Oklahoma City, Oklahoma 73126, or by calling, toll-free, 1-800-437-1011. I understand

that my right to revoke this authorization is limited to the extent that: AFAC has taken action in reliance on the authorization; or, the law provides AFAC with

the right to contest my insurance coverage or a claim under my insurance coverage.

I understand that if protected health information is disclosed, the information may be redisclosed only in accordance with any other state or federal

regulations.

For health insurance coverage this authorization will expire twenty-four months from the date it is signed or upon termination of my insurance policy,

whichever occurs first. For insurance coverage other than health insurance, this authorization will expire twenty-four months from the date it is signed or

upon expiration of my claim for benefits, whichever occurs first. For Arizona residents, release of HIV/AIDS-related information can only be disclosed for a

period not to exceed 180 days from the date shown below.

A copy of this authorization will be as valid as the original. I am aware that I, or my personal representative, am entitled to and will receive a copy of this

authorization.

Signature (Patient) or Personal Representative (if applicable)

Printed Name (Patient)

Relationship of Personal Representative to Patient

Date

If authorization is supplied by a personal representative, a description of the authority to act on behalf of the Insured must be included.

Please retain a copy for your personal records, or you may request a copy from our Company.

Warning: Any person who knowingly and with intent to injure, defraud, or deceive an insurer files a statement of claim containing any false, incomplete, or misleading information

may be guilty of insurance fraud and subject to criminal and civil penalties.

California - For your protection, California law requires the following to appear on this form. Any person who knowingly presents false or fraudulent claim for the

payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Ar, DC, LA, MD, NJ, NM, tX, and WV - ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIm FOR PAYmENT OF A LOSS OR BENEFIT OR

KNOWINGLY PRESENTS FALSE INFORmATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRImE AND mAY BE SUBJECT TO FINES AND CONFINEmENT

IN PRISON.

DE, iD, iN, MN, oh, and oK - WArNiNG: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false,

incomplete, or misleading information is guilty of a felony.

Colorado - It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting

to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company

who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or

claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the

department of regulatory agencies.

New hampshire - Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading

information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

Kentucky - Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or

conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

oregon - Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an application, or (2) by filing a claim containing

a false statement as to any material fact, may be guilty of insurance fraud.

Pennsylvania - Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing

any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime

and subjects such person to criminal and civil penalties.

Arizona - For your protection, Arizona law requires the following statement to appear on this form: Any person who knowingly

presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

Florida - Any person who knowingly, and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or

misleading information is guilty of a felony of the third degree.

hawaii - For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by

fines or imprisonment, or both.

BN-728 AWD

Routine Pregnancy Claim Form Page 2

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