SAG-AFTRA HEALTH PLAN
3601 W. Olive Ave., Burbank, CA 91505 • Mailing Address: P.O. Box 7830, Burbank, CA 91510-7830
P (800) 777-4013 • F (818) 953-9880 • www.sagaftraplans.org/health
Authorization for Release of Health Information Form
Send the completed, signed and dated form to the privacy officer at the mailing address above.
The SAG-AFTRA Health Plan (Plan) is required to have a separate form signed by each individual covered by the Plan age 18 and over.
This form does not serve as a change-of-address form.
Participant: _______________________________________________________________
Participant Social Security number (SSN): _____________ - ___________ - ___________
Patient (if different than participant): __________________________________________
(Check only one box): Participant Spouse Dependent (18 or older) Dependent (under 18)
Current address (street, city, state, zip): __________________________________________________________________________________________
____________________________________ ______________________________ _____________________________________
Daytime phone Home phone Email
1. Health information to be disclosed or used (check only one box)
Any and all information maintained by the Plan
Release only specific information related to eligibility/enrollment claims records claims status
Other (describe the specific health information you authorize the Plan to disclose): _______________________________________________________
2. Health information to be disclosed for the following specific purpose(s):
Medical care
Insurance/eligibility and benefits
Legal investigations or action
At my personal request
3. Name(s) and address(es) of person(s) or organization(s) authorized to receive the information. I understand that after this information is
disclosed, federal law might not protect it. More information is on the next page of this form.
________________________________________________________________________________________________________________________________________________________________________
Full name Address
______________________________________________________________________________________________________________________________
Full name Address
4. This authorization shall expire (check only one box)
On: _______________________(mm/dd/yyyy) (Must be a future date, not the date in the signature line)
Upon the occurrence of the following event related to my health care or to the purpose for which I have authorized the use and/or disclosure
described in section 2 above: _____________________________________________________________________________________________________
Important: If no box is checked, this authorization will expire two years after the date when this form was signed.
5. Signature of participant/patient (if not participant)
By signing this authorization, I authorize the Plan to disclose my protected health information (PHI) to the person(s) or organization(s) listed in section 3. I
have signed this authorization voluntarily to document my wishes regarding the disclosure of the health information described in sections 1 and 2 of this
form, and acknowledge that I have read and understand my rights described in section 7.
_____________________________________________________________________________________________________________________________
Signature of participant, spouse, dependent (age 18 or older) or parent of dependent (if under age 18) Date
6. If a personal representative is executing this form, please provide an explanation and documentation supporting his/her authority to
sign on behalf of the participant/patient. Check if documentation is attached.
_______________________________________ ________________________________________ _________________________________________
Personal representative (print) Signature of personal representative Relationship to participant/patient
The
Authorization for Release of Health Information Form
is required for release of protected health information (PHI) in compliance with the Health
Insurance Portability and Accountability Act (HIPAA) of 1996. This form authorizes the SAG-AFTRA Health Plan (Plan) to disclose your health information to
the person(s) and/or organizations you designate. If the person(s) and/or organization(s) listed in section 3 are not covered entities subject to federal
privacy standards, the health information disclosed pursuant to this authorization may no longer be protected by the federal privacy standards and such
person(s) and/or organization(s) may re-disclose my health information without obtaining my authorization.
7. Your rights regarding this authorization
Right to revoke. You have the right to revoke this authorization at any time. Your revocation of this authorization must be in writing. To obtain a copy
of an
Authorization Revocation Form
you may contact the Plan at the address listed below. Your revocation will not affect the disclosures of your PHI
that have already been made according to this authorization to the person(s) and/or organization(s) identified in section 3 of this authorization. I
understand that after this information is disclosed, federal law might not protect it.
Right to receive copy of this authorization. I understand I have the right to receive a copy of this authorization by contacting the privacy officer.
For an
Authorization Form
or a
Revocation Form
contact: Privacy Officer, SAG-AFTRA Health Plan, P. O. Box 7830, Burbank, CA 91510-7830
This individual authorizes the release of
his/her Protected Health Information (PHI).
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