**ATTENTION**
AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION
IN COMPLIANCE WITH HIPAA
I intend to procure and/or obtain information about health and life insurance products from my benefits agent. I understand that my agent may present information, products and tools related to health and life insurance products. I also understand that my agent may use my personal medical information to determine the appropriate health and life insurance products for me.
Your agent may conduct these presentations related to health and life insurance benefits to you by using the world wide web. I understand that these presentations may be monitored by other health and life insurance agents for instructional and quality control purposes. I understand that my personal medical information may be disclosed in this manner.
The type of information to be used or disclosed is as follows:
Complete copy of medical records
Final Diagnoses
Discharge Summaries
Histories
Physician examinations
Radiographic reports
Radiographic films
Emergency run reports		 Laboratory reports
Operative reports
Pathology reports
Progress notes
Physician orders
HIV results/AIDS
Office notes
Billing statements		 Emergency room treatments
Therapy notes
Clinical notes
Medication records
Evaluations
Consultations
Correspondence regarding patient
I understand that the information in my health record may include information related to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), AIDS-related conditions, and human immunodeficiency virus (HIV). it may also include information about behavioral or mental health services, and treatment for alcohol or drug abuse and drug-related conditions.
I further understand that:
  • Authorizing the disclosure or this health information is voluntary.
  • I can refuse to sign this authorization.
  • Treatment, payment, enrollment or eligibility for benefits may not be conditioned upon the tendering of this authorization.
  • I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524
  • Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by federal privacy regulations or other applicable state or federal laws.
  • This authorization may be revoked in writing and delivered to the above provider at any time however; such revocation does not effect actions taken by the provider before the provider received my written revocation. Revocation prevents the release of additional information. Furthermore, revocation will not apply to my insurance company when the law provides my unsurer with the right to contest a claim under my policy.
  • Unless otherwise revoked, this authorization will expire on the following date, event or condition: Sep 4, 2011
  • A copy of this Authorization may be used as an original
  Full Name of Customer or Representative:  
Re-Enter Full Name of Customer or Representative:
Full Name of Witness (Agent may act as witness):
Re-Enter Full Name of Witness:
If signed by a Legal Representative:
What is the full name of the patient:
Describe said Representative's authority to act for patient:
*Agent is required to obtain all necessary signatures.