Fillable AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION BY AUTHORIZED (Covered California)

Fill Online, Printable, Fillable, Blank AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION BY AUTHORIZED (Covered California) Form

Use Fill to complete blank online COVERED CALIFORNIA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION BY AUTHORIZED (Covered California)

On average this form takes 8 minutes to complete

The AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION BY AUTHORIZED (Covered California) form is 2 pages long and contains:

  • 0 signatures
  • 11 check-boxes
  • 25 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Covered California forms online.

BROWSE COVERED CALIFORNIA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
STATE OF CALIFORNIA
CALIFORNIA HEALTH BENEFIT EXCHANGE/COVERED CALIFORNIA (Exchange/CC)
AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION BY
AUTHORIZED REPRESENTATIVE
HBEX 404 (8/15)
Authorization for Release of Personal Information by a
Parent, Guardian, or Authorized Representative
This form authorizes Covered California to release a consumer’s personal information to the parties specified
by the Authorized Representative. To submit this request, please complete all necessary items and mail the
completed form and all relevant documents to:
Consumer Information
(As indicated on the consumer’s Covered California Account)
Last Name:
First Name:
Middle Initial:
Address:
City/State:
Zip Code:
Covered California Case or Account Number:
Date of Birth:
Parent, Guardian, or Authorized Representative’s Information
Last Name:
First Name:
Address:
City/State:
Daytime Phone Number (Required)
Email Address:
What legal authority do you have to act on behalf of the Consumer?
(Please attached legal documentation.)
Parent
Conservator
Executor of Will
Guardian
Agent of Health Care
Power of Attorney
Other
Privacy Officer
1601 Exposition Blvd.
Sacramento, CA 95815
AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION BY
AUTHORIZED REPRESENTATIVE
HBEX 404 (8/15)
Page 2
Attached Copy of Representative’s Identifying Information.
(If no identifying document is attached, your signature must be notarized.)
Driver’s License
State Identification Card
Federal Issued Identification Card
Notary
Date Notarized:
UNOFFICIAL UNLESS STAMPED BY NOTARY
PUBLIC
Notarized By:
Notary Public Number:
Authorization
I, ___________________________________________, hereby authorize Covered California, to release the
following information to the individual or entity identified below:
Name of Individual or Entity:
Street Address:
City/State:
Zip Code:
Day Time Phone Number:
Fax Number/Email Address:
Purpose of Release:
AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION BY
AUTHORIZED REPRESENTATIVE
HBEX 404 (8/15)
Page 3
Authorized Representative’s Signature
I understand that by signing this authorization:
I authorize the use or disclosure of the Consumer’s personal information as described above for the
purpose listed.
I have the right to withdraw permission for the release of the Consumer’s information. If I sign this
authorization to use or disclose information, I can revoke this authorization at any time and Covered
California will comply with the request within a reasonable amount of time. The revocation must be
made in writing and will not affect information that has already been used or disclosed.
I have the right to receive a copy of this authorization.
I am signing this authorization voluntarily.
I understand Covered California may not be able to comply with my request but will provide me with a
response.
I declare under penalty of perjury that the information on this form is true and correct.
Signature:
Date:
The information requested on this form is required by the California Health Benefits Exchange, Privacy
Office in order to process your request. The information you provide on this form is required to process your
request and will be used by the Privacy Office for that purpose. Failure to provide this information may result
in the denial of your request. Legal references authorizing the collection or maintenance of the information
provided on this form include Sections 1798.22, 1798.25, 1798.27 and 1798.35 of the California Civil Code
and Section 155.260(a) of the Code of Federal Regulations. California Health Benefits Exchange, Privacy
Office, 1601 Exposition Blvd, Sacramento, CA 95815 (800) 889-3871.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION BY AUTHORIZED (Covered California)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 19 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document