HRA_FSA_Release of PHI Form 5/17/2017
Participant Name:
Social Security Number:
I authorize MidAmerica Administrative & Retirement Solutions and its business associates to disclose claims, payment
and other related health information about me (other than psychotherapy notes) to the following persons (select 1-2
persons if desired):
Name: ____________________________________ Relationship: ____________________________
Name: ____________________________________ Relationship: ____________________________
I understand that this authorization will expire when I lose my plan eligibility and am not reinstated. I understand that I
have the right to revoke my authorization by advising the plan administrator in writing. This revocation will not be
effective to the extent that the authorization has already been relied upon.
I understand that my health information that is disclosed pursuant to this authorization may be disclosed by the persons I
have identified above AND I understand that I am not required to sign this form to receive my health care benefits
(enrollment, treatment or payment).
Participant Signature: ________________________ Date Signed: ____________________________
-OR-
I do not want my Health Information released to anyone but myself.
Participant Signature: ________________________ Date Signed: ____________________________
Please keep a copy of this release form for your records and submit a completed form to:
Mail: Fax:
MidAmerica Administrative & Retirement Solutions 863-577-4460
Dept: HRA Admin Questions?
P.O. Box 24927 Lakeland, FL 33802 855-329-0095
Health Reimbursement Arrangement (HRA)
Flexible Spending Account (FSA)
Authorization for Release of Protected Health Information
P.O. 24927 Lakeland, FL 33802
855.329.0095 ♦ Fax 863.577.4460 ♦ www.midamerica.biz
