Health Insurance Portability and Accountability Act (“HIPAA”) Authorization to Obtain and Disclose Information
Form number AGLC201528
I authorize the entities below to give American General Life Insurance Company, its affiliates and their authorized representatives, including insurance support organizations (collectively “Recipient”) the following information:
- any and all information relating to my health (except psychotherapy notes) including, but not limited to, information relating to any medical consultations, treatments, or surgeries; hospital confinements for physical and mental conditions; use of drugs or alcohol; prescriptions; 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 or practitioner group;
- any hospital, clinic, other health care facility, pharmacy, or pharmacy benefit manager; and
- the Medical Information Bureau (MIB).
I understand that the information obtained will be used by the Recipient to:
- determine my eligibility for insurance and benefits, and if a policy is issued, determine contestability of the policy;
- underwrite my application for insurance; and
- detect fraud or for compliance activities.
I hereby acknowledge that AGL and its affiliates are 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 Recipients requesting access to my (electronic or paper) medical records are acting as a patient authorized representative solely for the purpose of obtaining such records 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 AGL at the address provided on this form. I understand that my revocation of this authorization will not affect uses and disclosures of my health information by the Recipient for purposes listed above.
I understand that the signing of this authorization is voluntary; however, if I do not sign it, the Companies 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 and I am entitled to receive a copy of this authorization.
When you have finished reading the consent form above, please tell the person helping you with your application that you have read and agree to form number 201528.