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HIPAA Compliant Authorization | ADA-Sponsored Insurance Plans – Insurance for Dentists and Their Practices

Member HIPAA Compliant Authorization For Release Of Medical Information

Please read and eSign at the bottom.

I authorize MIB Inc., any health plan, physician, healthcare professional, hospital, clinic, laboratory, holders of prescription information on me, including but not limited to, pharmacies, pharmacy benefits managers, and insurers, medical facility, or other healthcare professional that has provided payment, treatment or services to me or on my behalf within the past 10 years (“My Providers”) to disclose my entire medical record, prescription history, medications prescribed, eligibility, prescribing physician, pharmacy information, insurance coverage information and any other protected health information concerning me to Great-West Life & Annuity Insurance Company. This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This also includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs and tobacco.

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.

This protected health information is to be disclosed under this Authorization so that Great-West Life & Annuity Insurance Company may administer claims and determine or fulfill responsibility for coverage and provision of benefits; administer coverage; and conduct other legally permissible activities that relate to any coverage I have or have applied for with Great-West Life & Annuity Insurance Company.

This authorization shall remain in force for 12 months following the date of my signature below and a copy of this authorization is as valid as the original. I understand that I have the right to revoke this authorization in writing, at any time, by providing written notification to the entity identified above. I understand that a revocation is not effective to the extent that any of “My Providers” have already relied on this Authorization to disclose information about me or to the extent that Great-West Life & Annuity Insurance Company has a legal right to contest a claim under an insurance policy or to contest the policy itself. I understand that any information that is disclosed pursuant to this authorization is no longer covered by federal rules governing privacy and confidentiality of health information, but will not be re-disclosed by Great-West Life & Annuity Insurance Company except as authorized by me or as required by law.

I understand that “My Providers” may not refuse to provide treatment or payment for healthcare services if I refuse to sign this authorization, or otherwise condition my enrollment or eligibility for health benefits on my signing this authorization. I further understand that if I refuse to sign this authorization to release my complete medical record, Great-West Life & Annuity Insurance Company may not be able to make any benefit payments. I understand that any authorized representative or I will receive a copy of this authorization upon request.

Member Legal First Name
Legal Last Name
ADA Number
Birthdate
Birth Date
Month
Day
Year

INSURED/PATIENT E-SIGNATURE

I,
*
* ,
am the owner identified in this HIPAA Authorization Form; I am electronically signing this HIPAA Authorization Form which includes and incorporates, 1. Notice to Applicants and 2. Authorization to Obtain and Disclose Information, and which will have the same effect as the execution of these documents by a written signature as valid legal binding as evidence of my intent and agreement to be bound. I consent to the use of an electronic record of the HIPAA authorization form as full satisfaction of any requirement these documents be provided to me in writing.
I,
*
* ,
agree to the above statement.

Date Signed: 11/24/2017 6:53 PM
Forms Center

Dentists:This website is not a contract. Benefits are provided under respective Group Policy Nos. (104TLP Annually Renewable Term Life, 1105GDH-IPP Disability Income Protection, 1106GDH-OEP Office Overhead Expense Disability, 104GUL Universal Life, 104LTLP Level Term Life, 1117GH-HIP Hospital Indemnity, 1127GH-CIP Critical Illness, and 1107GH-MCP MedCASHSM) filed in the State of Illinois in accordance with and governed by Illinois law, issued to the American Dental Association, and underwritten by Great-West Financial®. All ADA-sponsored coverage is subject to underwriting and is not guaranteed issue unless specifically stated otherwise. Coverage that is guaranteed issue is subject to a pre-existing condition limitation. The ADA is entitled to receive royalties from the ADA Members Insurance Plans. Coverage is available to all eligible ADA members and student members in all fifty states and U.S. territories under the aforementioned group policy. Level Term Life premiums are fixed based on the selected duration of 10 or 20 years. Must maintain membership throughout selected term. Annually Renewable Term Life, Hospital Indemnity, Critical Illness, and MedCASH premiums increase annually based on age. Recommended premiums under the Term Plus® Universal Life plan consist of the cost of insurance (which may vary based on the member’s age and coverage amount), the amount chosen by the member for deposit into his/her Policy Value Account and a service charge. Premium deposits may fluctuate or remain level depending upon the amount maintained in the Policy Value Account. Disability Income Protection premiums increase every 5 years and Office Overhead Expense every 10 years based on age. Premium credit for Annually Renewable Term Life and Term Plus Universal Life is not guaranteed but reevaluated annually. Premium credit for Disability Income Protection, Office Overhead Expense, Hospital Indemnity, Critical Illness, and MedCASH is not guaranteed but reevaluated semi-annually. Each Plan participant will receive a Certificate of Insurance explaining the terms and conditions of the policy.


Dental Students: This website is not a contract. Student coverage is issued regardless of your condition if you are under 45. If you are 45 or older, you can apply for the no-cost coverage and all student program features by providing proof of good health. Coverage renews automatically each academic year. Individuals may convert coverage to the plans for practicing dentists after graduation by paying ADA member premiums and maintaining ADA membership. Benefits are provided through a group policy Nos. (104TLP Term Life and 1108GDH-SDP Student Disability) filed in the State of Illinois in accordance with and governed by Illinois law, issued to the American Dental Association, and underwritten by Great-West Financial®. All ADA-sponsored coverage is subject to underwriting and is not guaranteed issue unless specifically stated otherwise. Coverage that is guaranteed issue is subject to a pre-existing condition limitation. Coverage is available to eligible ADA members and student members in all fifty states and US territories under the aforementioned group policy. Each insured will receive a certificate of insurance explaining the terms and conditions of the policy.


ADA® is a registered trademark of the American Dental Association and Great-West Financial® is a registered trademark of GWL&A.


Great-West Financial® refers to products and services provided by Great-West Life & Annuity Insurance Company, Greenwood Village, CO, its subsidiaries and affiliates. GWL&A is not licensed in New York, but eligible members residing in New York may request and ultimately receive coverage under the aforementioned group policy. The trademarks, logos, service marks, and design elements used are owned by Great-West Life & Annuity Insurance Company. ©2017 Great-West Life & Annuity Insurance Company. All Rights Reserved. For website issues, contact the Webmaster at ADA_WebMaster@greatwest.com.

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