Authorization for Release of Information
Please Print:
Employee Name: ___________________________ Social Security No: _________________
Work Location: _____________________________ Job Title: _________________________
Home Phone: ______________________________ Work Phone: ______________________
I voluntarily authorized the Jordan School District Insurance Department to release information
related to the items check below to the following individual(s):
Name: _____________________________________________________________________
Relationship to Employee: ______________________________________________________
Phone Number: ______________________________________________________________
Name: _____________________________________________________________________
Relationship to Employee: ______________________________________________________
Phone Number: ______________________________________________________________
SPECIFIC INFORMATION (select one or more as appropriate)
All Benefit Related Information
Only the Items Checked below:
Health Insurance Life Insurance
Dental Insurance Flexible Spending
Vision Insurance Long Term Disability
Other: (please explain) _______________________________
Expiration Date of Disclosure Authorization: When do you want this authorization to expire?
No Expiration Date Specify Date or Expiration: ______________________
You may change or revoke authorization at any time by completing a new Authorization for Release
form.
Check here to REVOKE any and all prior authorizations on file.
_______________________________________ __________________
Date Employee Signature (No electronic signatures)
7387 W. Campus View Dr.
West Jordan, UT 84084
Phone: 801-567-8146
Fax: 801-567-8070
www.jordandistrict.org/departments/insurance
