Primary Certificate Holder Name:
Date of Birth:
Certificate Number(s):
Name of Individual Subject to Disclosure (If not the primary Certificate Holder):
Relationship to Primary Certificate Holder:
Spouse Domestic Partner Child Stepchild Grandchild
For the purpose of evaluating my eligibility for insurance and for benefits under an existing certificate, including checking
for and
resolving any issues that may arise regarding incomplete or incorrect information on my application for coverage
and/or claim form, I
hereby authorize the disclosure of the following information(defined below) about me and, if
applicable, my dependents, from the
sources listed below to Continental American Insurance Company (CAIC), or any
person or entity acting on its part, to include American
Family Life Assurance Company of Columbus and American
Family Life Assurance Company of New York (collectively, “Aflac).
Disclosure of Health Information:
Health information may be disclosed by any health care provider, health plan (including CAIC or Aflac, with respect to other
CAIC or Aflac
coverages) or health care clearinghouse that has any records or knowledge about me. Health care provider
includes, but is not limited to,
any licensed physician, medical or nurse practitioner, nurse, pharmacist, osteopath,
psychologist, physical or occupational therapist,
chiropractor, dentist, audiologist or speech pathologist, podiatrist, hospital,
medical clinic or laboratory, pharmacy, rehabilitation facility,
nursing home or extended care facility, prescription drug
database or pharmacy benefit manager, or ambulance or other medical transport
service. Health information may also be
disclosed by any insurance company or the Medical Information Bureau (MIB). Health information
includes my entire
medical record, but does not include psychotherapy notes. Some information obtained may not be protected by certain
federal r
egulations governing the privacy of health information, but the information is protected by state privacy laws and
other applicable
laws. CAIC will not disclose the information unless permitted or required by those laws.
Rights and Expiration:
I understand that I may revoke this authorization at any time, except to the extent that CAIC or Aflac has taken action in
reliance on this
authorization. If I revoke this authorization, CAIC may not be able to evaluate my application for coverage
and/or claim. To revoke this
authorization, I must provide a written and signed revocation to CAIC at the address or fax
number above. Unless otherwise revoked,
this authorization shall remain in effect for two (2) years from the date signed
or upon my death, whichever occurs first. I agree that a
copy of this authorization is as valid as the original and that I or an
authorized representative may request a copy of this authorization.
I understand that CAIC is not conditioning payment, enrollment, or eligibility for benefits on whether I sign this
authorization. I
understand that if the information disclosed is protected health information relating to a health plan and the
person or entity receiving
the information is a not a health care provider or health plan covered by federal privacy
regulations, the information disclosed may be
re-disclosed by such person or entity and will likely no longer be protected
by the federal privacy regulations.
If records are on an adult dependent, (e.g. spouse, child over 18), the dependent must sign this form
If records are on a minor child the natural parent or legal guardian must sign on their behalf.
Signature of Individual Subject to Disclosure Date Signed
Legal Representative’s Printed Name Legal Representative’s Signature Legal Relationship Date
***If signed by a legal representative (e.g. Legal Guardian, Estate Administrator, Power of Attorney***
Send to:
Continental American Insurance Company
Post Offce Box 84075
Columbus, GA 31993
Phone: (800) 433-3036
Fax: (866) 849-2970