Fillable Authorization For Release of Personal Information & Appointment (Covered California)

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Authorization For Release of Personal Information & Appointment (Covered California)

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The Authorization For Release of Personal Information & Appointment (Covered California) form is 3 pages long and contains:

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  • 15 check-boxes
  • 24 other fields

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File type: PDF

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STATE OF CALIFORNIA
CALIFORNIA HEALTH BENEFIT EXCHANGE/COVERED CALIFORNIA (Exchange/CC)
AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION & APPOINTMENT OF
REPRESENTATIVE
HBEX 403 (07/17)
Authorization For Release of Personal Information & Appointment of Representative
This form authorizes Covered California to release your personal information to the parties specified in this
request. To submit this request, please complete all necessary items and mail the completed form and all
relevant documents to:
Privacy Officer
1601 Exposition Blvd.
Sacramento, CA 95815
Consumer Information
(As indicated on your Covered California Account)
Last Name: First Name: Middle Initial:
Address: City/State: Zip Code:
Covered California Case or Account Number: Date of Birth:
Daytime Phone Number: Email Address
Consumer Address Verification
(Please attached a copy of one of the following with your name and current address.)
California Driver’s License
Utility Bill
Other
Consumer Identity Verification
(Please attached a copy of one of the following. If no identifying document is attached, your signature must
be notarized.)
California Driver’s License
State of California Identification Card
Federal Issued I.D. Card
Notary
Date Notarized:
UNOFFICIAL UNLESS STAMPED BY NOTARY
PUBLIC
Notarized By:
Notary Public Number:
AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION & APPOINTMENT OF
REPRESENTATIVE
HBEX 403 (07/17)
Page 2
Consumer Authorization
By my signature, I hereby authorize Covered California, to release the following personal information to the
individual or entity identified below:
Name of Individual or Entity:
Street Address:
City and State: Zip Code:
Day Time Phone Number:
Fax Number/Email Address:
Purpose of Release:
Consumer Appointment
I would also like to appoint the individual identified above to serve as my Authorized Representative.
By checking this box, you are authorizing the individual identified above to make decisions pertaining to
your Covered California account, which could potentially affect your healthcare coverage. If you do not
wish for the person listed above to have this authority, please leave this box unchecked. Otherwise,
please sign below and have your Authorized Representative complete the remainder of this form.
By signing this authorization, I acknowledge and agree that:
If the box above is checked, the individual identified above who has been authorized to access my
personal information will serve as my Authorized Representative in any and all matters pertaining to my
account with Covered California.
Once the individual listed above has been appointed to serve as my Authorized Representative, I
further understand and acknowledge that he or she will have the authority to make decisions pertaining
to my Covered California account, which could potentially affect my healthcare coverage.
I authorize the disclosure or use of my personal information as described above for the purpose listed.
I have the right to withdraw permission for the release of my information and to revoke my Authorized
Representative’s authority to act on my behalf at any time. Covered California will comply with my
request within a reasonable period of time, however, I understand that any such withdrawal or
revocation will not affect any information that was used or disclosed prior to withdrawal or revocation.
I have the right to receive a copy of this authorization.
I am signing this authorization voluntarily.
Consumer Signature
By my signature below, I declare under penalty of perjury that the information on this form is true and correct.
Signature: Date:
AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION & APPOINTMENT OF
REPRESENTATIVE
HBEX 403 (07/17)
Page 3
By signing this authorization, I acknowledge and agree that:
I have been designated by the above-referenced consumer to serve as the Authorized Representative
in any and all matters pertaining to his or her Covered California account and to make decisions which
may affect the above-referenced consumer’s healthcare coverage.
I will at all times strictly maintain the confidentiality of the consumer’s personal information and shall at
no time disclose or use any such information for purposes not authorized by the consumer.
I further agree to fully comply with any applicable federal or state laws pertaining to conflicts of interests
and the confidentiality of the consumer’s personal information.
My Authorized Representative appointment will remain valid until the consumer notifies Covered
California that I am no longer authorized to serve as his or her Authorized Representative or until I
notify Covered California that I am no longer acting as the consumer’s Authorized Representative.
I have the right to receive a copy of this authorization.
I am signing this authorization voluntarily.
Authorized Representative Signature
By my signature below, 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 Benefit Exchange to process your
request and will be used solely for this 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 Benefit Exchange, Privacy Office, 1601
Exposition Blvd, Sacramento, CA 95815 (800) 889-3871.
Authorized Representative Address Verification
(Please attached a copy of one of the following with your name and current address.)
California Driver’s License
Utility Bill
Other
Authorized Representative Identity Verification
(Please attached a copy of one of the following. If no identifying document is attached, your signature must be
notarized.)
California Driver’s License
State of California Identification Card
Federal Issued I.D. Card
Notary
Date Notarized:
UNOFFICIAL UNLESS STAMPED BY NOTARY
PUBLIC
Notarized By:
Notary Public Number:
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Authorization For Release of Personal Information & Appointment (Covered California)

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Completed 19 May 2021

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