Authorization for the Release of Medical Information
All States
This authorization complies with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.
I hereby authorize the use or disclosure of health information, as described below, about me or my below-named unemancipated minor children and revoke any previous restrictions concerning access to such information:
Person(s) or group(s) of persons authorized to use and/or disclose the information: Any health plan, physician, health care professional, hospital, clinic, long-term care facility, medical or medically-related facility, laboratory, pharmacy, pharmacy benefit manager, insurance company [including Transamerica Life Insurance Company (“the Company”)], insurance support organization such as MIB, Inc. (“MIB”), or other medical practitioner or health care provider that has provided payment, treatment or services to me or on my behalf or to or on behalf of my unemancipated minor children.
Person(s) or group(s) of persons authorized to collect or otherwise receive and use the information: The Company, its affiliates and reinsurers, and their agents, employees, or other representatives. I further authorize the Company and its affiliates and reinsurers to redisclose the information to MIB.
Description of the information that may be used or disclosed: This authorization specifically includes the release of all information related to my health or that of my unemancipated minor children and my or my unemancipated minor children’s insurance policies and claims, including, but not limited to, information on the diagnoses, prognoses, treatments, prescription drug information, and information regarding diagnosis, prognosis and treatment of mental illness, communicable or infectious conditions, such as HIV or AIDS, and use of alcohol, drugs and tobacco. This Authorization excludes psychotherapy notes that are separated from the rest of my medical records.
The information will be used or disclosed only for the following purpose(s): For the purpose of underwriting my insurance application with the Company and, if a policy is issued, for evaluating contestability and eligibility for benefits, for the continuation or replacement of the policy, for reinstatement of the policy or to contest a claim under the policy.
Statements of Understanding & Acknowledgement:
I understand that health information about me provided to the Company may be protected by state and federal privacy regulations including the HIPAA Privacy Rule and that the Company will only use and disclose such information as permitted by applicable regulations and as described in its privacy notices. However, I also understand that any information disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal regulations such as the HIPAA Privacy Rule governing privacy and confidentiality of health information.
I understand that if I refuse to sign this authorization to release my health information or that of my unemancipated minor children, the Company may not be able to process my application, or if coverage is issued may not be able to make any benefit payments.
I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it, or to the extent that other law provides the Company with the right to contest a claim under the policy or the policy itself, by sending a written revocation to the Company’s Privacy Official at the address at the top of this form. I also understand that the revocation of this authorization will not affect uses and disclosures of my health information for purposes of treatment, payment and business operations, including agent commission statements.
This authorization shall remain in force for 24 months (12 months in Kansas) from the date signed, regardless of my condition and whether living or deceased
I acknowledge that I have received a copy of this authorization.
Authorization for the Release of Medical Information
California
This authorization complies with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.
I hereby authorize the use or disclosure of health information, as described below, about me or my below-named unemancipated minor children and revoke any previous restrictions concerning access to such information:
Person(s) or group(s) of persons authorized to use and/or disclose the information: Any health plan, physician, health care professional, hospital, clinic, long-term care facility, medical or medically-related facility, laboratory, pharmacy, pharmacy benefit manager, insurance company [including Transamerica Life Insurance Company (“the Company”)], insurance support organization such as MIB, Inc. (“MIB”), or other medical practitioner or health care provider that has provided payment, treatment or services to me or on my behalf or to or on behalf of my unemancipated minor children.
Person(s) or group(s) of persons authorized to collect or otherwise receive and use the information: The Company, its affiliates and reinsurers, and their agents, employees, or other representatives. I further authorize the Company and its affiliates and reinsurers to redisclose the information to MIB.
Description of the information that may be used or disclosed: This authorization specifically includes the release of all information related to my health or that of my unemancipated minor children and my or my unemancipated minor children’s insurance policies and claims, including, but not limited to, information on the diagnoses, prognoses, treatments, prescription drug information, and information regarding diagnosis, prognosis and treatment of mental illness, communicable or infectious conditions, such as HIV or AIDS, and use of alcohol, drugs and tobacco. This Authorization excludes psychotherapy notes that are separated from the rest of my medical records.
The information will be used or disclosed only for the following purpose(s): For the purpose of underwriting my insurance application with the Company and, if a policy is issued, for evaluating contestability and eligibility for benefits, for the continuation or replacement of the policy, for reinstatement of the policy or to contest a claim under the policy.
Statements of Understanding & Acknowledgement:
I understand that health information about me provided to the Company may be protected by state and federal privacy regulations including the HIPAA Privacy Rule and that the Company will only use and disclose such information as permitted by applicable regulations and as described in its privacy notices. However, I also understand that any information disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal regulations such as the HIPAA Privacy Rule governing privacy and confidentiality of health information.
I understand that if I refuse to sign this authorization to release my health information or that of my unemancipated minor children, the Company may not be able to process my application, or if coverage is issued may not be able to make any benefit payments.
I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it, or to the extent that other law provides the Company with the right to contest a claim under the policy or the policy itself, by sending a written revocation to the Company’s Privacy Official at the address at the top of this form. I also understand that the revocation of this authorization will not affect uses and disclosures of my health information for purposes of treatment, payment and business operations, including agent commission statements.
This authorization shall remain in force for 24 months from the date signed, regardless of my condition and whether living or deceased.
I acknowledge that I have received a copy of this authorization.
Authorization for the Release of Medical Information
Maine
This authorization complies with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.
I hereby authorize the use or disclosure of health information, as described below, about me or my below-named unemancipated minor children and revoke any previous restrictions concerning access to such information:
Person(s) or group(s) of persons authorized to use and/or disclose the information: Any health plan, physician, health care professional, hospital, clinic, long-term care facility, medical or medically-related facility, laboratory, pharmacy, pharmacy benefit manager, insurance company [including Transamerica Life Insurance Company (“the Company”)], insurance support organization such as MIB, Inc. (“MIB”), or other medical practitioner or health care provider that has provided payment, treatment or services to me or on my behalf or to or on behalf of my unemancipated minor children.
Person(s) or group(s) of persons authorized to collect or otherwise receive and use the information: The Company, its affiliates and reinsurers, and their agents, employees, or other representatives. I further authorize the Company and its affiliates and reinsurers to redisclose the information to MIB.
Description of the information that may be used or disclosed: This authorization specifically includes the release of all information related to my health or that of my unemancipated minor children and my or my unemancipated minor children’s insurance policies and claims, including but not limited to, information on the diagnoses, prognoses, treatments, prescription drug information, and information regarding diagnosis, prognosis and treatment of mental illness, use of alcohol, drugs and tobacco, communicable or infectious conditions, excluding HIV. This Authorization excludes psychotherapy notes that are separated from the rest of my medical records.
The information will be used or disclosed only for the following purpose(s): For the purpose of underwriting my insurance application with the Company and, if a policy is issued, for evaluating contestability and eligibility for benefits, for the continuation or replacement of the policy.
Statements of Understanding & Acknowledgement:
I understand that health information about me provided to the Company may be protected by state and federal privacy regulations including the HIPAA Privacy Rule and that the Company will only use and disclose such information as permitted by applicable regulations and as described in its privacy notices. However, I also understand that any information disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal regulations such as the HIPAA Privacy Rule governing privacy and confidentiality of health information.
I understand that if I refuse to sign this authorization to release my health information or that of my unemancipated minor children, the Company may not be able to process my application, or if coverage is issued may not be able to make any benefit payments.
I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it, or to the extent that other law provides the Company with the right to contest a claim under the policy or the policy itself, by sending a written revocation to the Company’s Privacy Official at the address at the top of this form. I also understand that the revocation of this authorization will not affect uses and disclosures of my health information for purposes of treatment, payment and business operations, including agent commission statements.
This authorization shall remain in force for 24 months from the date signed, regardless of my condition and whether living or deceased.
I acknowledge that I have received a copy of this authorization.
The hospital will provide you with a discharge summary report when you are released from the hospital.
Diagnostic Report
Your doctor/hospital will provide you with a diagnostic report.
Pathology Report
Your doctor/hospital will provide you with a pathology report.
Date of Diagnosis
Please provide documentation of your date of diagnosis.
Authorization Form
A signed authorization form is recommended, as some providers will not accept an electronic signature.
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