LINE CONSTRUCTION BENEFIT FUND
AUTHORIZATION TO DISCLOSE HEALTH INFORMATION
Member Name: Member Unique ID
(Please Print)
Address:
Member Telephone No.:
Patient’s Name:
In the course of providing health plan coverage, the LINE CONSTRUCTION BENEFIT FUND (LINECO)
may obtain private health information about you or your dependent child(ren). Except as permitted by law
and Federal regulations, LINECO will not disclose that private health information to any person or entity.
LINECO WILL NOT condition payment of a claim, enrollment in a plan or eligibility for benefits on your
decision to sign this Authorization Form. You are not required to sign this form.
This Authorization Form is only effective if it is signed by the person whose medical information is to be
disclosed, or by someone authorized to sign for that person. If the person whose medical information is to
be disclosed is a child under age 18, a parent living with the child can sign on behalf of the child.
1. Persons and Organizations Authorized to Receive and Use My Health Information.
_____________________________________________________________________
I understand that the individual or organization named above are not health care providers or
health plans that are subject to Federal privacy standards and that disclosing my health
information pursuant to this authorization creates a risk of redisclosure without my authorization.
2. Persons and Organizations Authorized to Disclose My Health Information.
This authorization applies to LINECO and to all of their employees, representatives and agents
having access to my health information.
3. Description of Health Information to Be Used or Disclosed. In order to enable another person
or organization to assist me in obtaining benefits from LINECO, I want this authorization to apply to
all information concerning my eligibility and medical treatment. NOTE: This form does not
authorize the disclosure, release or use of psychotherapy notes.
This authorization allows LINECO to disclose and use any health information unless I
specify otherwise on the following lines. This authorization DOES NOT apply to:
_____________________________________________________________________
_____________________________________________________________________
4. Purpose of the Requested Use and/or Disclosure. I authorize my health information to be used
and/or disclosed for all purposes that the individual or organization named above, in their sole
discretion, deem necessary or advisable to assist me in obtaining benefits from LINECO.
5. Your Rights with Respect to This Authorization. You have the right to revoke this authorization
at any time. Any revocation must be in writing, sent or delivered to 821 Parkview Boulevard,
Lombard, Illinois 60148. A revocation will not be effective as to uses and/or disclosures of your
health information that have already made in reliance upon this authorization prior to receipt of
your written revocation.
6. Expiration of Authorization. Unless you do not insert an earlier date or event on the
following line this authorization will expire 30 months from the date on which you sign it.
This authorization will expire for the purpose of the use or disclosure on .
