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Basics

Gender

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Your SSN helps us get you approved for this policy, it is never shared!

Address

Contact

Additional Information

These details allow us to get you approved quicker and easier

Driver’s License

Do you have a driver’s license?

AUTHORIZATION FOR THE RELEASE OF MEDICAL RECORDS

American-Amicable Life Insurance of Texas (here after referred to as the Company). This Authorization complies with the HIPAA Privacy Rules.

The Authorization must be fully completed as a condition of obtaining coverage. A refusal to sign this authorization will result in a rejection of your application for the insurance. A copy of this authorization will be considered as valid as the original.

  1. I hereby authorize the following person(s) or group of persons to disclose information to the company: Any and all physicians, medical practitioners, hospitals, clinics, medical or medically-related facilities, health plans, pharmacy benefit managers, pharmacies or pharmacy-related facilities; insurance companies and their business associates and those persons or entities providing services to the insurers’ business associates which are related in any way to their insurance plans.
  2. This authorization specifically includes the release of all medical records including without limitation those containing information relating to diagnoses, treatments, consultation, care, advice, laboratory or diagnostic tests, physical examinations, recommendations for future care, prescription drug information, alcohol or drug abuse, mental illness or information regarding communicable or infectious conditions, such as HIV and/or AIDS.
  3. Person(s) or group of persons authorized to receive and use the information: The Company and its business associates and those persons or entities providing services to the Company plans.
  4. The information will be used to make enrollment/eligibility for benefit determinations, specifically including, but not limited to, underwriting and risk rating determinations. If coverage is issued, such determinations may include determinations as to whether coverage should be rescinded or reformed if I have made any material omission(s) or misrepresentation(s) in my application.
  5. I understand that any information that is disclosed pursuant to this authorization may be redisclosed and no longer covered by federal rules governing privacy and confidentiality of health information.
  6. I understand that I may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance on this authorization or the insurance company exercises a legal right to contest a claim or the policy itself. I may revoke the authorization by sending a written revocation to the Company address of 425 Austin Ave, Waco TX 76701.
  7. I understand that if I refuse to sign this authorization to release my complete medical records, my application for insurance with the Company will be rejected.
  8. This authorization will expire 24 months after the date signed.

I agree