FORM OF AUTHORIZATION
Authorization for the Use or Disclosure of Protected Health Information
Required by the Health Insurance Portability and Accountability Act,
45 C.F.R. Parts 160 and 164
- I hereby voluntarily authorize the disclosure of information from my health record in accordance with this Authorization.
- The information is to be disclosed by Association Member Benefits Advisors, LLC (“AMBA”), on behalf of benefit and insurance companies Retired Indiana Public Employees Association (RIPEA) Insurance Trust.
- The purpose of the disclosure is to enable RIPEA Insurance Trust to identify those of its members who have purchased benefit programs and insurance coverage through AMBA.
- The information to be disclosed is only my name and the fact that I have elected to purchase a benefit or insurance program through AMBA.
- If this authorization has not been revoked, it will be in effect until the termination of my insurance or benefit program that was purchased through AMBA, at which time this authorization expires.
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