Fillable Patient Authorization Form (City of Oakland)

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Patient Authorization Form (City of Oakland)

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DOCTORS AND/OR MEDICAL FACILITIES AUTHORIZED TO RELEASE MY HEALTH INFORMATION:
Name Address Telephone Fax Dates Treated
You are authorized to release any health information that may have bearing on the request for
benefits submitted in conjunction with the travel protection plan to: CSA Travel Protection and
Insurance Services, its affiliates, underwriters, reinsurers, and any agent expressly acting on behalf of
CSA Travel Protection and Insurance Services. Additionally, if there is potential fraudulent activity you
release medical information related to the identification and prevention of the fraudulent activity to
the underwriters, insurance support organizations, fraud information clearinghouses and designated
service providers assisting in the processing of the claim.
Send to: CSA Travel Protection and Insurance Services
Attn: Claims Department, P.O. Box 939057, San Diego CA 92193-9057
FAX: 877-300-8670. Information to be released: Physician Dictation, Physical and/or Occupational
Therapy Records, Office Notes, Lab Reports, Entire Record,
Other:
I UNDERSTAND THE FOLLOWING:
•Ifapplicable,HIV/AIDS,genetictesting,abuse,drugs/alcoholand/ormentalhealthrecordswillbe
included in the health information that is released.
•Imayrevokethisauthorizationtothehealthinformationmanagementdepartmentinwriting.My
revocation will not apply to my insurance company when the law provides my insurer with the right
tocontestaclaimundermypolicy.Unlessrevoked,thisauthorizationwillexpireinsixmonths.
•Imayinspectorcopytheinformationtobeusedordisclosed,asprovidedinCFR164.524.Any
disclosure of information carries with it the potential for any unauthorized re-disclosure and the
information may not be protected by federal confidentiality rules. I am entitled to a copy of this
authorization. A facsimile or photocopy can be treated as the original.
•THEINFORMATIONAUTHORIZEDFORRELEASEMAYINCLUDERECORDSWHICHMAYINDICATETHE
PRESENCEOFACOMMUNICABLEDISEASEORNONCOMMUNICABLEDISEASE.
• Mytreatment,payment,orenrollmentmaynotbeconditionedonsigningthisauthorization.If
I refuse to sign this authorization, benefits may not be paid under the travel protection plan if
additional health information is needed to determine my eligibility for benefits.
Name of Patient:
Date of Birth:
SS#:
Purposeofrelease:TRAVELINSURANCECLAIM
Patient Authorization Form
Signature of patient or authorized person Date:
Relationship/Reason patient is unable to sign
Patient Authoraziation Form_8651_081809
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Patient Authorization Form (City of Oakland)

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Completed 5 March 2021

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