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500385 Rev. 11/2014
I authorize any physician, medical professional or other health care provider, hospital or other medical facility; pharmacy; health plan;
other medically related entity; rehabilitation professional; vocational evaluator; employee assistance plan; insurance company,
reinsurer, health maintenance organization, third party administrator, broker or other insurance service provider, or similar entity; the
Medical Information Bureau; the Association of Life Insurance Companies, which operates the Health Claims Index and the Disability
Income Record System; government organization or agency, including the Social Security Administration; financial institution,
accountant or tax preparer; consumer reporting agency; and employer or group policyholder that has information about my health,
prescriptions, financial, earnings or employment history, or other insurance claims and benefits to provide access to or copies of this
information to the Plan and to any individual or entity who provides services to or insurance benefits on behalf of the Plan, including
but not limited to the requesting company(ies) named below ("Company"). To the extent I may be eligible for governmental benefits
similar to or that coordinate with those available to me under the Plan, I also authorize disclosure of information necessary to apply for
or determine my eligibility for such benefits to the relevant government agency and/or vendor providing application assistance.
For any claim for insurance benefits, this authorization is valid for the shorter of 24 months or the duration of my claim. For all other
permitted disclosures, this authorization is valid for one (1) year from the date below. I am entitled to a copy of this authorization and a
photographic or electronic copy of it is as valid as the original.
Disclosure Authorization
AUTHORIZATION
I understand that any information obtained with this authorization will be used for evaluating and administering my coverage,
including any claim for benefits, or otherwise providing services related to or on behalf of the Plan, which may include, but is not
limited to assisting me in returning to work and Plan administration. With respect to governmental benefits similar to or that
coordinate with benefits available to me under the Plan, I understand that the information will be used to help determine my eligibility
for any such benefits and may include assisting me in applying for the benefits. I understand that the information disclosed under this
authorization is subject to redisclosure and may no longer be protected by certain federal regulations governing the privacy of health
information, although it will continue to be protected by other applicable privacy laws and regulations.
I understand that I do not have to give this authorization. If I choose not to give the authorization - or if I later revoke - I understand
that the Plan, insurers, or other providers of services or benefits related to the Plan who rely on this authorization may not be able to
evaluate or administer my request for Plan benefits, coverage or services and that my request for Plan benefits, coverage or services
may be denied as a result. I may revoke this authorization by sending written notice to the Claim Manager handling my claim.
Claimant’s Name:
Information about my health may relate to any disorder of the immune system including but not limited to HIV and AIDS; use of drugs
or alcohol; and mental and physical history, condition, advice or treatment, but does not include psychotherapy notes.
NOTE: This authorization is designed to comply with HIPAA and relates to information necessary to administer coverage and services
under your employer’s employee health and welfare plan(s) ("the Plan") and similar or coordinating governmental benefits. You are not
required to sign the authorization, but if you do not, the Plan, insurers or other providers of services or coverage under the Plan may
not be able to process your request for Plan benefits, coverage or services.
Company Names: Life Insurance Company of North America, Cigna Life Insurance Company of New York, Cigna Worldwide Insurance
Company, Great-West Life & Annuity Insurance Company, First Great-West Life & Annuity Insurance Company, New England Life
Insurance Company, Alta Health & Life Insurance Company and Connecticut General Life Insurance Company.
(Date of Birth)(Print Name)
(Claimant’s Signature) (Date Signed)
Guardian, or Conservator, please attach a copy of the document granting authority.
(indicate relationship). If Power of Attorney Designee,
I signed on behalf of the claimant as
If my employer [union, group association] sponsors any other plans, whether or not underwritten or administered by a Cigna company,
the information and/or records obtained may also be shared with the underwriting company (insurer) or administrators of those other
plans, including their internal or external health management, disease management, wellness, employee/member assistance program
or other similar programs, for the purpose of administering any service, benefit or feature described in those plans.
