HIPAA Authorization:
I hereby authorize any of the following persons or entities to give any information or records about me or my mental or physical health (my "Health Information") to Modern Life Group, Inc. ("Modern Life") to assist me with obtaining insurance benefits: government agency, financial institution, employer, credit reporting agencies, educational institutions, any health system, hospital, clinic, pharmacy, or other health care or medical facility; any physician, nurse, medical practitioner or other licensed health care professional; any laboratory or other entity or organization, institution or person, that provides or arranges medical exams or laboratory tests; any health plan or third party administrator of a health plan; any electronic health record provider; any health information exchange; any pharmacy benefit manager or pharmacy-related service organization; any health care clearinghouse; any insurance or reinsurance carrier or agent, including those to which I have applied or from which I have obtained insurance; any other entity or person that is subject to the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations ("HIPAA'') or the Confidentiality of Substance Abuse Disorder Regulations at 42 C.F.R. Part 2.
I understand that Modern Life will use and share my Health Information it receives from the persons and entities included in this document to determine my eligibility for insurance and/or benefit payment, to contest coverage, and/or to conduct legally permissible actuarial, audit and research activities. To accomplish this, I authorize Modern Life to share my Health Information with the following types of third parties: any Authorized Insurance Company (collectively, “Authorized Insurance Companies," listed below), reinsurers and policy underwriters; health care providers, laboratories, and other entities that arrange for and provide medical exams and laboratory tests on behalf of any Authorized Insurance Company and policy underwriters; medical records vendors, including but not limited to medical advisors, underwriting consultants, services, script checks; and other third parties and agents as needed to support the insurance-related purposes described above.
I acknowledge and agree that the above data and facts will be used to (1) underwrite an application for coverage (2) obtain reinsurance (3) resolve or contest any issues of incomplete, incorrect, or misrepresented information on the application identified above, which may arise during the processing or review of the application, or any other application for insurance; (4) administer coverage and claims; and (5) complete a consumer report, investigative consumer report or telephone interview about the proposed insured or claimant.
I understand that my Health Information may include the following types of information about me: my entire medical record, including any information regarding health diagnoses and treatment, medications or prescription drugs used, and prognosis of any physical or mental health condition; laboratory records, diagnostic test results, and pathology reports; insurance claims history and other information about payment for health care services; and any "individually identifiable health information," as such term is defined by HIPAA. I also understand that my Health Information may include highly sensitive information about me (collectively, “Sensitive Health Information"). I specifically request and authorize the persons and entities included in this document to provide my Sensitive Health Information from the following categories to Modern Life: information related to the testing or diagnosis of, or treatment for, communicable, venereal, or sexually transmitted disease, including, but not limited to, HIV/AIDS; genetic test results or information; mammography test results; substance use information, including information related to the diagnosis of, or treatment for, alcohol or drug abuse; information about mental health, mental illness, or developmental disabilities; confidential communications with a psychotherapist, psychologist, social worker, sexual assault counselor, domestic violence counselor or other mental health professional or human services professional, including psychotherapy notes; information about family planning or abortion services; and information about sexual assault, child abuse and neglect, or abuse of an adult with a disability.
Duration:
I understand that if any Health Information is re-disclosed by the recipient, it may no longer be protected by HIPAA, but it may be protected by other applicable federal and state laws. This Authorization may be revoked at any time by writing Modern Life at 295 Lafayette Street, Suite 701 New York, New York 10012. I am also able to revoke my authorization in writing by contacting the health care provider, health plan, or other person or entity listed in this document that shared my Health Information with Modern Life. The revocation does not affect actions taken before revocation. Unless revoked, this Authorization is valid for two years from execution, unless a shorter period is required by applicable law. This Authorization is voluntary and not conditioned on treatment, payment, enrollment, or eligibility for benefits. I have the right to receive a copy of this Authorization. A photographic copy of this authorization shall be as valid as the original.
MIB Authorization: I hereby authorize MIB, LLC (MIB) to give my Health Information to the Authorized Insurance Company, its reinsurers, or its authorized third-party administrator, and for those parties to to make a brief report of my Health Information to MIB.
HMR-0001
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