NEW YORK LIFE INSURANCE COMPANY, 51 MADISON AVE, New York, NY 10010
NEW YORK LIFE INSURANCE AND ANNUITY CORP. (A Delaware Corporation)
NEW YORK LIFE INSURANCE COMPANY OF ARIZONA (Not licensed in every State)
AUTHORIZATION
Insured’s Name:
(Please print the name of the person on whom information is being sought.)
I authorize medical information concerning the above named Insured to be released to New York Life, its agents, its employees, its
affiliates, and acting on its behalf: attorneys, reinsurers, insurance support groups, and independent administrators. This authorization applies
to any physician; health care professional, hospital, clinic, laboratory; pharmacy, medical facility, hospice, nursing home, assisted living
facility, home health care agency, other medical facility; adult day care provider, adult foster care provider, or other health care provider;
insurance company, group policyholder or benefit plan administrator that has provided payment, treatment or services to the above named
Insured within the last five years and permits them to disclose medical records covering such payment, treatment or services, to New York
Life, for the purpose of evaluating this claim for benefits. This includes, but is not limited to, all data reports and records that contain
history, findings, diagnosis, prognosis and treatment(s) about the named Insured’s physical and mental health, medical examinations or tests,
prescriptions, medical diagnosis and prognosis, HIV infection, any disorder of the immune system including Acquired Immune Deficiency
Syndrome (AIDS) or AIDS Related Complex (ARC), mental or emotional illness, the use of drugs, the use of alcohol, the use of tobacco,
but excludes psychotherapy notes. This also includes any portion of the named Insured’s medical records during this period I have
previously withheld from release, which I hereby terminate for the purposes of this authorization.
I also authorize the release of non-medical information concerning the above named Insured, including other insurance coverage,
employment history, earnings or finances, driving records, or information otherwise needed to determine policy claim benefits due. This
information can be released by any consumer reporting agency, insurance support organizations, the Social Security Administration, the
Internal Revenue Service, the Veteran’s Administration, offices of the government, employers, insurance companies, group policyholders,
benefit plan administrators, or any other organization or person having any knowledge of the above named Insured.
I agree the information obtained by this authorization may be used by New York Life to determine eligibility for claimed benefits with
respect to the above named Insured. I know I have the right to revoke this authorization at any time by notifying New York Life Insurance
and Annuity Corporation, in writing, at the address shown on this authorization. My revocation will not be effective to the extent New
York Life or any other person already has disclosed, collected information, or taken other action in reliance on it. My revocation will also
not be effective to the extent state law gives New York Life the right to contest a claim under the policy or the policy itself.
I understand that if I revoke, or fail to sign this Authorization, or alter its content in any way, New York Life will not be able to process my
claim for benefits.
I know that I can request a copy of this authorization. A copy of this authorization shall act as the original. This authorization is valid for
two years from the date shown below unless revoked by me in writing.
The information New York Life obtains based on this authorization may be subject to further disclosure. For example, New York Life
may be required to provide it to an insurance regulatory or other government agency. In this case, the information may no longer be
protected by the rules governing this authorization.
Date Insured’s Signature*
(Insured or Insured’s authorized representative)
Relationship if other than Insured
* If the subject of information is incapacitated, the Authorization form must be signed by an authorized representative such as a conservator, guardian,
or power of attorney.
22030 (12/08)
