FORM WFI.HIPAA2.EF3/10 © 2010 Welcome Funds Inc
WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
AUTHORIZATION FOR THE DISCLOSURE OF PROTECTED HEALTH INFORMATION (SECONDARY INSURED)
I, __________________________________ (the undersigned individual), DOB____________SS#________________, hereby authorize
disclosure, as defined under the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of
1996, of my protected health information (“PHI”) as follows:
1. Classes of Persons Authorized to Disclose My PHI. I authorize each doctor, hospital, nurse, pharmacy, physician, physician
practice group, and any other type of health care provider (each, an “HCP”) having any PHI about me to disclose any and all of my
PHI as provided under this authorization. I authorize each Authorized HCP to rely upon a photostatic or facsimile copy or other
reproduction of this authorization.
2. Classes of Persons Authorized to Receive My PHI.
I authorize each Authorized HCP to disclose my PHI under this authorization
to WELCOME FUNDS INC including any of its affiliates, agents, subsidiaries, corporate parents, independent contractors,
consultants, service providers and authorized representatives and the officers, directors and employees of each, and to any oth
er
person or entity required or compelled by law to receive or view such PHI to evaluate, facilitate, underwrite and solicit bids for the
sale of my life insurance policy(ies), including but not limited to medical underwriters, lenders, financing entities,
br
okers/brokerages, buyers of life insurance policies, life expectancy providers and stop-loss re-insurers and his or their aff
iliates,
agents, subsidiaries, corporate parents, independent contractors, consultants, service providers and authorized representatives and the
officers, directors and employees of each (each, an “Authorized Recipient”). I understand that my PHI may be secured by and
electronically transmitted to an Authorized Recipient, including but not limited to transmission via e-mail and posting to a password
protected, secure website.
3. Description of PHI Authorized for Disclosure and Purpose of Disclosure.
This authorization shall apply to any and all of my
health and medical data, information and records, whether or not personally or individually identifiable or protected under any federal
or state confidentiality or privacy laws or regulations. This authorization and all disclosures of my PHI made under this authorization
are for purposes of allowing the Authorized Recipient to analyze, assess, evaluate or underwrite my health or medical condition, or
life expectancy, in connection with the possible sale of any life insurance policy, or certificate of life insurance, under which my
life
is in
sured. In addition, I acknowledge that some state and federal laws prohibit the further disclosure of drug, alcohol or HI
V related
information without specific written consent. This authorization shall serve as such consent in order for each Authorized Recipient to
perform the functions described herein.
4. Expiration of Authorization.
This authorization shall remain valid until, and shall expire, one year after the date of my death or the
maximum period as allowed by state or federal law.
5. Right to Revoke Authorization.
I acknowledge and understand that I may revoke this authorization any time with respect to any
Authorized HCP by notifying such Authorized HCP in writing of my revocation of this authorization and delivering my revocation
by mail or personal delivery at such address designated to me by such Authorized HCP; provided, that, any revocation of this
authorization shall not apply to the extent that the Authorized HCP has taken action in reliance upon this authorization prior to
receiving written notice
of my revocation.
6. Ina
bility to Condition Treatment, Payment, Enrollment or Eligibility for Benefits on Provision of Authorization.
No HCP or
other covered entity may condition my treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization.
I understand that a) this Authorization is not a consent or an authorization requested by a health care provider, health care clearinghouse
or health plan covered by the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of
1996 (the “HIPAA Privacy Regulations”); b) as a result of this Authorization, there is the potential for my PHI that is disclosed by any
Authorized HCP to an Authorized Recipient to be subject to re-disclosure by the Authorized Recipient and my PHI that is disclosed to
such Authorized Recipient may no longer be protected by the HIPAA Privacy Regulations; and c) my ongoing health status may be
tracked as a result of this Authorization.
I certify that I am executing and delivering this authorization freely and unilaterally and that all information contained in this
authorization is true and correct. I further certify that this authorization is written in plain language and that I have received and retained a
copy of this signed authorization for future reference.
____________________________________________________________________________________________
List of Authorized Disclosers (AD) (Hospitals, Doctors, Etc.):
‘
Authorized by:
___________________________________________ _________________________________ ________
Signature of Individual (Secondary Insured) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Legal Representative of Secondary Insured (if any) Printed Name Date
Description of Legal Representative’s Authority (if any):
___________________________________________________________________________________
(POA, Guardian ad Litem or similar status – Please attach legal documents for verification)
