Protected Health Information (PHI) to be Used and/or Disclosed: Any and all information or records relating to the medical history, medical examinations, services rendered, or treatment given, including treatment for alcohol abuse, substance abuse, mental or emotional disorders, AIDS (Acquired Immune Deficiency Syndrome), or ARC (AIDS-related complex
Entities or Persons Authorized to Use or Disclose: U.S. Department of Health and Human Services (including the Centers for Medicare & Medicaid Services and any contractors or agents, including Medicare intermediaries), any physician or other health care professional, hospital or other health care facility, counselor, therapist, Pharmacy Benefit Manager or any other medical or medically related facility or professional.
Entities or Persons Authorized to Receive: New Era Life Insurance Company (NEL), New Era Life Insurance Company (NEM) or Philadelphia American Life Insurance Company (PAL) or its agents, employees, designees, or representatives, including my NEL, NEM or PAL agent or broker.
Purpose of this Authorization: By signing this form, you will authorize NEL, NEM or PAL to use and/or disclose your Protected Health Information (PHI) to determine if your application will be approved for health insurance or that you are eligible for benefits. This authorization is a condition of your approved application for our health insurance or your eligibility for benefits.
You also will authorize NEL, NEM or PAL to obtain your Protected Health Information (PHI) from other covered entities so that we may determine payment of a claim for specified benefits involving you. Effect of Declining: If you decide not to sign this authorization, we may decline to approve your application for health insurance or to provide benefits.
This authorization may facilitate our consideration of a claim. If you decide not to sign this authorization, it may delay the processing of a claim. Effect of Granting this Authorization: The PHI to be used and/or disclosed may be subject to re-disclosure by the recipient, in which case it would no longer be protected under the HIPAA Privacy Rule.
Expiration: This authorization will expire upon the termination of any NEL, NEM or PAL coverage that may be in effect.
Right to Revoke: I understand that I may revoke this authorization at any time by giving written notice of my revocation to: New Era Life Insurance Company, New Era Life Insurance Company of the Midwest or Philadelphia American Life Insurance Company, P.O. Box 4884, Houston, TX. 77210-4884.