HIPAA Authorization For Release Of Medical Information
Please read and eSign at the bottom.
I authorize any health plan, physician, healthcare professional, hospital, clinic, laboratory, or holders of prescription
information on me, including but not limited to: pharmacies and pharmacy benefits managers, and insurers, medical
facilities, or other healthcare professionals that have provided payment, treatment or services to me or on my behalf
(“My Providers”) to disclose my entire medical record, prescription history, medications prescribed, eligibility,
prescribing physician, pharmacy information, insurance coverage information and any other protected health
information concerning me to Great-West Life & Annuity Insurance Company (the Company). 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
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 any physician, healthcare professional, hospital, clinic, medical facility,
or other healthcare provider to release and disclose my entire medical record without restriction.
This protected health information is to be disclosed under this Authorization so that Great-West Life & Annuity
Insurance Company may: 1) evaluate my application for insurance coverage or claims benefits, determine eligibility
and risk rating; 2) obtain reinsurance; 3) administer coverage and claims; 4) conduct other legally permissible
activities that relate to any coverage I have or have applied for with Great-West Life & Annuity Insurance 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 providing written notification to the entity identified above. I understand that a revocation is not effective to
the extent that any of “My Providers” have already relied on this Authorization to disclose information about me or to
the extent that Great-West Life & Annuity Insurance 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
is no longer covered by federal rules governing privacy and confidentiality of health information, but will not be
re-disclosed by Great-West Life & Annuity Insurance Company except as authorized by me or as required by law.
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 the Authorization to release my complete medical
record, Great-West Life & Annuity Insurance Company may not be able to process my application, or if coverage has
been issued, may not be able to make any benefit payments.
Member Legal First Name
12/15/2018 7:39 PM