HIPAA Compliant Authorization for Life Insurance
I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, prescription benefit manager, or other health care provider that has provided payment, treatment or services to me or on my behalf within the past 10 years (collectively, "My Providers") to disclose my entire medical record, prescription drug information, and any other protected health information concerning me to Amplify Life Insurance Company (“Company”), The Company's agents, employees, and Life Insurance Carriers that they are submitting my applications to. 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, but excludes psychotherapy notes.
By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to this Authorization and I instruct My Providers to release and disclose my entire medical record without restriction.
The protected health information and driving records are to be disclosed under this Authorization so that The Company may:
- submit and underwrite my application for coverage, make eligibility, risk rating, policy issuance and enrollment determinations
- obtain reinsurance
- administer claims and determine or fulfill responsibility for coverage and provision of benefits
- administer coverage
- conduct other legally permissible activities that relate to any coverage I have or have applied for with The Company
This Authorization shall remain in force for 30 months following the date of my signature below, 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 Amplify Life Insurance at 2111 Lane Street #24560, San Francisco, CA 94124-0560. I understand that a revocation is not effective to the extent that 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 re-disclosed and no longer covered by 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 to release my complete medical record, 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 acknowledge that I have received a copy of this Authorization.