SI 2047 6 of 7 (2/09)
Authorization to Obtain and Release Information
Standard Insurance Company
The Standard Life Insurance Company of New York
The Standard Benefit Administrators
I AUTHORIZE THESE PERSONS having any records or knowledge of me or my health:
• Any physician, medical practitioner or health care provider.
• Any hospital, clinic, pharmacy or other medical or medically related facility or association.
• Kaiser Permanente.
• Any insurance company or annuity company.
• Any employer, policyholder or plan sponsor.
• Any organization or entity administering a benefit or leave program (including statutory benefits) or an annuity program.
• Any educational, vocational or rehabilitation counselor, organization or program.
• Any consumer reporting agency, financial institution, accountant, or tax preparer.
• Any government agency (for example, Social Security Administration, Public Retirement System, Railroad Retirement Board, Workers’
Compensation Board, etc.).
TO GIVE THIS INFORMATION:
• Charts, notes, x-rays, operative reports, lab and medication records and all other medical information about me, including
medical history, diagnosis, testing and test results. Prognosis and treatment of any physical or mental condition, including:
• Any disorder of the immune system, including HIV, Acquired Immune Deficiency Syndrome (AIDS) or other related
syndromes or complexes.
• Any communicable disease or disorder.
• Any psychiatric or psychological condition, including test results, but excluding psychotherapy notes. Psychotherapy notes
do not include a summary of diagnosis, functional status, the treatment plan, symptoms, prognosis and progress to date.
• Any condition, treatment, or therapy related to substance abuse, including alcohol and drugs.
and:
• Any non-medical information requested about me, including such things as education, employment history, earnings or
finances, return to work accommodation discussions or evaluations and eligibility for other benefits or leave periods
including but not limited to claims status, benefit amount, payments, settlement terms, effective and termination dates,
plan or program contributions, etc.
TO STANDARD INSURANCE COMPANY, THE STANDARD LIFE INSURANCE COMPANY OF NEW YORK, THE STANDARD
BENEFIT ADMINISTRATORS AND THEIR AUTHORIZED REPRESENTATIVES (referred to as “The Companies”, individually
and collectively), AND MY EMPLOYER’S ABSENCE MANAGEMENT PROGRAM ADMINISTRATOR (“Absence Manager”).
• I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization
and I instruct the persons and organizations identified above to release and disclose my entire medical record without restriction.
• I understand that each of The Companies and Absence Manager will gather my information only if they are administering
or deciding my disability or leave of absence claim(s), and will use the information to determine my eligibility or entitlement
for benefits or leave of absence.
• I understand that I have the right to refuse to sign this authorization and a right to revoke this authorization at any time
by sending a written statement to The Companies and Absence Manager, except to the extent the authorization has been
relied upon to disclose requested records. A revocation of the authorization, or the failure to sign the authorization, may
impair The Companies and Absence Manager’s ability to evaluate or process my claim(s), and may be a basis for denying
or closing my claim(s) for benefits or leave of absence.
• I understand that in the course of conducting its business The Companies and Absence Manager may disclose to other
parties information about me. They may release information to a reinsurer, a plan administrator, plan sponsor, or any person
performing business or legal services for them in connection with my claim(s). I understand that The Companies and Absence
Manager will release information to my employer necessary for absence management, for return to work and accommodation
discussions, and when performing administration of my employer's self-funded (and not insured) disability plans.
• I understand that The Companies and Absence Manager comply with state and federal laws and regulations enacted to
protect my privacy. I also understand that the information disclosed to them pursuant to this authorization may be subject to
redisclosure with my authorization or as otherwise permitted or required by law. Information retained and disclosed by The
Companies and Absence Manager may not be protected under the Health Insurance Portability and Accountability Act [HIPAA].
• I understand and agree that this authorization as used to gather information shall remain in force from the date signed below:
• For Standard Insurance Company, the duration of my claim(s) or 24 months, whichever occurs first.
• For The Standard Life Insurance Company of New York, the duration of my claim(s) or 24 months, whichever occurs first.
• For The Standard Benefit Administrators, the duration of my claim(s) administered by The Standard Benefit
Administrators or 24 months, whichever occurs first.
• For Absence Manager, 24 months.
• I understand and agree that The Companies and Absence Manager may share information with each other regarding my
disability and leave of absence claim(s). This authorization to share information shall remain valid for 12 months from the
date signed below.
• I acknowledge that I have read this authorization and the New Mexico notice on page 7. A photocopy or facsimile of this
authorization is as valid as the original and will be provided to me upon request.
Name (please print) Social Security No.
Signature of Claimant/Representative Date
If signature is provided by legal representative (e.g., Attorney in Fact, guardian or conservator), please attach documentation of legal status.
