National Roofers Union & Employers Joint Health & Welfare Fund
Authorization for Release of Protected Health Information (PHI) By the Health Fund
You MUST complete all of the information requested in this form for your authorization to be valid.
I authorize the Fund the use of disclosure of my Protected Health Information (PHI) as described in this authorization. I understand
the Fund may not condition my treatment, payment, enrollment or eligibility for benets on whether or not I give the authorization
listed in this form.
(1) The Plan can release PHI to: The Fund, its agents or subcontractors (“Business Associates”) is authorized to release the
PHI described below to the following person, class of persons, or organization:
My spouse My Union
My parents My Employer
Other (Print Name or Position): ______________________________________________________________________
(2) The information that may be used or released is:
Medical information held by the Fund from the following doctor, clinic, or hospital:
___________________________________________________________________________________________________
Information held by the Fund concerning my eligibility, claims decisions and payments.
Other. Please specify below.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
(3) Right to revoke: I understand that I have the right to revoke this authorization at any time by notifying the Fund’s Contact
Person in writing at the address listed at the top of this Form. I understand that the revocation is only eects after it
is received and logged by the Fund. I understand that any use or disclosure made prior to the revocation under this
authorization will not be aected by a revocation.
(4) Re-Release of Information: I understand that after this information is released, federal law might not protect it and
the recipient might re-release it I also understand and agree to hold the Fund and any of its agents and subcontractors
harmless if the information is re-released.
(5) Copy: I understand that the Fund will give me a copy of this authorization
(6) THE AUTHORIZATION WILL EXPIRE ON THE DATE ON WHICH YOUR ELIGIBILITY UNDER THE PLAN TERMINATES
UNLESS YOU SPECIFY ANOTHER DATE OR TERMINATION EVENT BELOW.
Other: __________________________________________________________________________________________
Your Signature: _______________________________________________________ Date: __________________________________
Print Your Name: ____________________________________________________________________________________________
If you are covered under the Fund as a Dependent, please print the name and social security number of the covered employee:
Name: ___________________________________________________________ SSN: ______________________________________
Mail or Fax Completed Forms to the Fund Administrator:
3001 Metro Drive – Suite 500, Bloomington, MN 55425
Fax: 952-854-1632
