I, the Insured/Proposed Insured above or the Insured/Proposed Insured’s Personal Representative acting on behalf of the Insured/Proposed Insured, hereby authorize all of the people and organizations listed below to give Security Benefit Life Insurance Company (“Security Benefit”), and any affiliated company, and their authorized representatives, including agents and insurance support organizations, (collectively, the “Recipient”), the following information:
any and all information relating to my health (except psychotherapy notes) and my insurance policies and claims, including, but not limited to, information relating to any medical consultations, treatments, or surgeries; hospital confinements for physical or mental conditions; use of drugs or alcohol; prescription drugs; and communicable diseases including HIV or AIDS; and Information about me, including my name, address, telephone number, gender, and date of birth.
I hereby authorize each of the following entities (“Providers”) to provide the information outlined above:
- Any physician, nurse or medical practitioner group;
- Any hospital, clinic, or other health care facility, pharmacy, or pharmacy benefit manager;
- Any insurance or reinsurance company (including, but not limited to, the Recipient which may have provided me with life, accident, health, and or disability insurance coverage, or to which I may have applied for insurance coverage, but coverage was not issued);
- Any consumer reporting agency or insurance support organization;
- My employer, group policy holder, or benefit plan administrator; and
- The MIB, Inc.
I understand that the information obtained will be used by the Recipient to:
- Determine my eligibility for insurance;
- Underwrite my application for insurance;
- Determine my eligibility for benefits;
- If a policy is issued, determine my eligibility for benefits and contestability of the policy; and detect fraud or abuse or for compliance activities, which may include disclosure to MIB and participation in MIB’s fraud prevention or fraud detection programs.
I hereby acknowledge that the Recipient is subject to certain federal privacy regulations. I understand that information released to the Recipient will be used and disclosed as described in the Notice of Health Information Privacy Practices, but that upon disclosure to any person or organization that is not a health plan or health care provider, the information may no longer be protected by federal privacy regulations.
I understand that the Recipient requesting access to my (electronic or paper) medical records are acting as a patient authorized representative and will attempt to access my medical records in an efficient manner, including electronic interchange through a Health Information Exchange or directly through my Providers’ electronic health record system.
I may revoke this authorization at any time, except to the extent that action has been taken in reliance on this authorization or other law allows the Recipient to contest a claim under the policy or to contest the policy itself, by sending a written request to: Security Benefit Life, PO Box 78506, Attn: Underwriting, Topeka, Kansas 66675-8506. I understand that my revocation of this authorization will not affect uses and disclosures of my health information by the Recipient for purposes of underwriting, claims administration and other matters associated with my application for insurance coverage and the administration of any policy issued as a result of that application. I understand that the signing of this authorization is voluntary; however, if I do not sign the authorization, the Recipient may not be able to obtain the information necessary to consider my application.
This authorization will be valid for 24 months. A copy of this authorization will be as valid as the original. I understand that I am entitled to receive a copy of this authorization
LI-10000-10 HIPAA Authorization Form 2021-01-04