XGR/1641 LTD Claim Packet - Claimant Page 8 of 12
Claimant: DOB: Policy no.: CC no:
Sun Life Assurance Company of Canada
Authorization for Release and Disclosure of Health Related Information
This Authorization complies with the HIPAA Privacy Rule.
It is important for you to read, sign and submit all Authorizations in this packet. Failure to submit all Authorizations could
result in a delay during the claims process.
I HEREBY AUTHORIZE any physician, healthcare provider, health plan, medical professional, hospital, clinic, laboratory,
pharmacy benefit manager or other medical or healthcare facility that has provided payment, treatment or services to me or on
my behalf to disclose my entire medical record and any other protected health information concerning me to the Claims
Department of Sun Life Assurance Company of Canada (“the Company”), its subsidiaries, affiliates, third party administrators
I understand that such information may include records relating to my physical or mental condition such as diagnostic tests,
physical examination notes and treatment histories, which may include information regarding the diagnosis and treatment of
human immunodeficiency virus (HIV) infection, sexually transmitted diseases, mental illness and the use of alcohol, drugs and
tobacco, but shall not include psychotherapy notes.
By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply
to this Authorization, and I instruct any physician, healthcare professional, hospital, clinic, medical facility or other healthcare
provider to release and disclose my entire medical record without restriction.
I understand that the Company may use the information it obtains to: (a) underwrite my application for coverage; (b) make
eligibility, risk rating, policy issuance and enrollment determinations; (c) obtain reinsurance; (d) administer claims and determine
or fulfill responsibility for coverage and provision of benefits; (e) administer coverage; (f) assist my employer in reviewing and
evaluating requests for statutory leaves and/or accommodations as part of the interactive process under the Americans with
Disabilities Act or other applicable laws; and/or (g) conduct other legally permissible activities that relate to any coverage I have
or have applied for with the Company, including but not limited to any request for leave or workplace accommodation.
I authorize the Company to disclose information it obtains about me to the following persons to the extent necessary for the
recipient to provide claim management or advisory services, to audit the administration of claims, or to verify, evaluate and/or
adjudicate my claim: (a) my employer, its agents, and any plan sponsor, administrator or other service provider of any benefit
plan in which I participate or leave/accommodation services associated with my employment; (b) my treating physicians,
psychologists and therapists/counselors; (c) other persons or organizations performing medical, investigative, financial or legal
services related to my claim; (d) my insurer, if the Company is acting only as the administrator of my claim and; (e) other
insurance companies, third party administrators or insurance support organizations to prevent fraud or material nondisclosure in
connection with insurance transactions. The Company will not disclose information it obtains about me except as authorized by
this Authorization, as may be required or permitted by law; or as I may further authorize. I understand that if information is re-
disclosed as permitted by this authorization, it may no longer be protected by applicable federal privacy law.
I understand that: (a) this Authorization shall be valid for 24 months from the date of signature; (b) I may revoke it at any time
by providing written notice to Sun Life Assurance Company of Canada, One Sun Life Executive Park, Wellesley Hills,
Massachusetts, 02481, subject to the rights of any person who acted in reliance on it prior to receiving notice of its revocation;
and (c) my authorized representative and I are entitled to receive a copy of the Authorization upon request.
A copy of this Authorization shall be as valid as the original.
Print name of employee or personal representative of employee
Group policy number
If Representative, description of your authority or relationship to employee
Signature of employee or personal representative