Authorization for Release of Protected Health Information

Better Insure It!

Please complete a separate Authorization for Release of Protected Health Information (PHI) for each dependant for whom you are being requested to disclose PHI to a third party.

If this form is not fully completed, as applicable, the insurance company will be unable to process your request. Incomplete authorization requests will be returned.

Insured's Name(Required)

First Middle Last

Insured's Email(Required)

Insured's Address

Street Address Address Line 2 City State ZIP Code

Insurance Carrier(Required)

Primary Applicant Information

Name(Required)

First Middle Initial Last

ID Number(Required)

Group Number(Required)

Group Name(Required)

Birth Date(Required)

Phone (Including Area Code)(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Dependent Information

Name(Required)

First Middle Initial Last

ID Number(Required)

Group Number(Required)

Group Name(Required)

Birth Date(Required)

I authorize the individual(s) or company(ies) identified below to receive PHI pertaining to the member identified in Section 1 above.*(Required)

I only want to share the PHI I have checked below. This authorization cannot be used to share psychotherapy notes. (Check all that are appropriate(Required)

Disability

Life benefits

Long Term Care

Any information requested

Claim status Claim records

Patient management records Application or enrollment information

Behavioral Health (e.g. mental health, substance abuse, but NOT psychotherapy notes)

Health (includes medical, dental, pharmacy, vision, and flexible spending account information)

Other (please explain)

Explanation

100% Satisfaction Guarantee

Exceeding Customer Expectations

Authorization for Release of Protected Health Information

Primary Applicant Information

Dependent Information

Quick menu

What to Expect

Resources

Contact

Speak To A Professional Today!