500385 Rev. 04/2021
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Disclosure Authorization
Claimant’s Name:
NOTE: This authorization is designed to comply with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and
relates to information necessary to administer benefits and services under Employer’s employee health and welfare plan(s) ("the
Plan") and statutory and/or private leave of absence or job accommodation programs. "Employer” is defined to mean your
employer, or your family member’s employer to the extent benefits, services, or leave are being sought under your family member’s
employer’s Plan. You are not required to sign the authorization, but if you do not, the Plan, insurers or other providers may not be
able to process your (or your family member’s) request for benefits or services under the Plan or statutory and/or private leave of
absence or job accommodation programs.
AUTHORIZATION
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; social security
disability advocate or representative; 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 (whether by written, telephonic or electronic
means) to Life Insurance Company of North America; New York Life Group Insurance Company of NY (Life Insurance Company of
North America and New York Life Group Insurance Company of NY shall be collectively referred to as "Insurance Company"); and
any other individual or entity (including nonaffiliated third parties) that provides services to or insurance benefits on behalf of the
Plan and/or Employer’s statutory and/or private leave of absence or job accommodation programs. If I am also covered by Cigna
Health and Life Insurance Company or its affiliates (“Cigna”), I authorize Insurance Company to disclose the health and other
information described above to Cigna to assist me with my health coverage and to provide its services and benefits. This
information will be shared to coordinate benefits and provide other services to you.
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 or
genetic information.
I agree and understand that any information obtained with this authorization may be used and disclosed for the following
purposes: 1) evaluating and administering coverage, including any claim for benefits, or otherwise providing services related to or
on behalf of the Plan; 2) evaluating and administering services related to Employer’s statutory and/or private leave of absence or job
accommodation programs; 3) determining my eligibility for any governmental benefits similar to or that coordinate with benefits
available to me under the Plan and assisting me in applying for such benefits; and 4) evaluating and administering benefits or
services under any other plans sponsored by or offered through Employer such as health management, disease management,
wellness, or employee/member assistance programs.
I understand that the information disclosed under this authorization is subject to redisclosure and may no longer be protected by
HIPAA or other federal regulations governing the privacy of health information, although it may continue to be protected by other
applicable privacy laws and regulations. I further understand that if any information is used for services relating to Employer’s leave
of absence or job accommodation programs, that information may be disclosed to Employer at any time. Additionally, I understand
that information may be disclosed to the employee who elected my coverage or submitted a claim for benefits under my coverage,
or requested leave.
This authorization shall be valid for 12 months or the duration of my claim for insurance benefits, whichever is longer. I also
understand that Insurance Company will maintain a copy of this authorization, and that I am entitled to a copy of this authorization
and a photographic or electronic copy of it is as valid as the original.
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 or Employer’s statutory and/or private leave of
absence or job accommodation programs who rely on this authorization may not be able to evaluate or administer any request for
benefits, coverage or services and that any request for benefits, coverage or services may be denied as a result. I may revoke this
authorization by sending written notice to the Claim Manager handling the claim.
(Claimant’s Signature)
(Date Signed)
(Print Name) (Date of Birth)
I signed on behalf of the claimant as (indicate relationship). If Power of Attorney Designee, Guardian, or
Conservator, please attach a copy of the document granting authority.
© 2020 - 2021, New York Life Insurance Company, New York, NY. All rights reserved. NEW YORK LIFE and the New York Life box logo are registered trademarks of New
York Life Insurance Company. Life Insurance Company of North America and New York Life Group Insurance Company of NY are subsidiaries of New York Life
Insurance Company. Cigna Health and Life Insurance Company is not affiliated with New York Life Insurance Company.
