Authorization to Obtain and Release Information Form
This document is an authorization form allowing specified entities to obtain and release personal, health, and non-medical information. It includes details on who may disclose information, what information may be disclosed, and who may receive the information. It is essential for determining or recommending eligibility for insurance benefits.
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How do I fill this out?
To fill out this form, first ensure you have read and understand the authorization. Identify and provide the necessary personal and medical information required. Finally, sign and date the form to authorize disclosure of your information.
How to fill out the Authorization to Obtain and Release Information Form?
1
Read and understand the authorization.
2
Identify and list the persons or entities who may disclose information.
3
Specify the information that may be disclosed.
4
Identify the persons or entities who may receive the information.
5
Sign and date the form.
Who needs the Authorization to Obtain and Release Information Form?
1
Employees who need to authorize their employer to access medical or non-medical information.
2
Insurance claimants who need to provide authorization to their insurance company.
3
Patients who need to authorize their healthcare providers to release medical records.
4
Individuals applying for disability benefits who need to provide information to evaluators.
5
Applicants for leave or benefits who need to authorize program administrators to access relevant information.
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What are the instructions for submitting this form?
Submit the completed form via mail, fax, or email. Mail to: Standard Insurance Company, P.O. Box 711, Portland, OR 97207. Fax to: 1-800-378-6053. Email to: disabilityclaims@standard.com. Ensure all required fields are filled out and the form is signed and dated. My advice is to keep a copy of the submitted form for your records.
What are the important dates for this form in 2024 and 2025?
This form should be submitted as soon as possible for processing. No specific dates for 2024 and 2025 are mentioned.
What is the purpose of this form?
The purpose of this form is to authorize the disclosure and release of personal, health, and financial information to specified entities. This information is necessary to determine eligibility and entitlement to insurance benefits, disability claims, leave administration, and other purposes. By completing this form, you ensure that the relevant parties have the necessary information to process your claims and requests efficiently.
Tell me about this form and its components and fields line-by-line.
- 1. Disclosure Entities: List of persons or organizations authorized to disclose information about the claimant.
- 2. Information to be Disclosed: Specify the types of information that may be disclosed.
- 3. Receiving Entities: Identify the persons or entities who may receive the disclosed information.
- 4. Authorization Agreement: Acknowledgement and agreement to the terms of the authorization.
- 5. Signature and Date: Signature of the claimant or their representative, along with the date of signing.
What happens if I fail to submit this form?
Failure to submit this form may result in delays or denial of claims, benefits, or leave requests. Authorization for necessary information might be incomplete, affecting the evaluation of your eligibility.
- Claim Denial: The claim might be denied due to lack of authorized information.
- Benefit Delay: Processing of benefits may be delayed without the required authorization.
- Incomplete Evaluations: Evaluations for eligibility might be incomplete or inaccurate.
- Impaired Processing: Entities might face difficulties processing your requests efficiently.
How do I know when to use this form?
- 1. Insurance Claims: Authorize insurance companies to access your information for claim processing.
- 2. Disability Benefits: Provide information to determine eligibility for disability benefits.
- 3. Leave Administration: Authorize your employer or third parties to manage your leave requests.
- 4. Medical Record Release: Allow healthcare providers to release your medical records.
- 5. Benefit Eligibility: Ensure relevant parties have the required information to evaluate your benefit eligibility.
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What types of information can be disclosed using this form?
Medical, non-medical, and financial information can be disclosed as authorized.
Who can receive the information disclosed in this form?
Entities such as insurance companies, employers, and healthcare providers can receive the disclosed information.
How long is the authorization valid for?
The authorization is valid for 12 months from the date signed or the duration of the claim, whichever occurs first.
Can I revoke the authorization?
Yes, you can revoke the authorization by sending a written statement to the marked entities.
Can I review the confidential abuse information provided to Standard Insurance Company?
Yes, you have the right to request a copy of the confidential abuse information and request corrections if needed.
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