| 1. |
As a participant in my Employers' Group Health Plan (the "Plan"), I hereby authorize the issuance of a password and the use or disclosure of, including access to, my Protected Health Information (as defined in the Privacy Standards) as described in this Authorization. |
| 2. |
It is my desire that a password be issued so that I may access information regarding my claims under the Plan, as well as those of my dependents, if any, (the "Dependents"). Further, I may wish to disclose this password to the Dependents. I recognize that by issuance and use of this password, I am authorizing the third party administrator of the Plan, Tucker Administrators, Inc. ("TPA"), to disclose to the Dependents and I my Protected Health Information. |
| 3. |
The Protected Health Information that may be accessed and disclosed through use of the password includes, with respect to myself and the Dependents who are covered under the Plan, the following:
| a. |
Information regarding enrollment in the Plan. |
| b. |
Information regarding claims filed, including date of service, provider of service, amount charged and general description of services rendered. |
| c. |
Information regarding payment and denial of claims, including the reason for denial of any claims. |
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| 4. |
I understand that if I make this password available to the Dependents, it will allow them to access the information described in Item 3 above and I hereby authorize such access. |
| 5. |
This Authorization shall expire within ten business days following my termination as a participant in the Plan. |
| 6. |
I understand that I have the right to revoke this Authorization by delivering a written notice of my desire to revoke this Authorization to TPA at their offices at 3800 Arco Corporate Drive, Charlotte, NC 28273, Suite 450, Attn: Anne Parker/Senior Vice President. The revocation will be effective ten business days following TPA's receipt of my written notice. I understand that I cannot revoke this Authorization to the extent that the Plan or TPA, on behalf of the Plan, have taken action in reliance on this Authorization (for example, any disclosure made prior to the revocation under this Authorization will not be affected by the revocation). |
| 7. |
I understand that the information described in Item 3 above, once disclosed to the Dependents, may be re-disclosed by those individuals and no longer protected by the Privacy Standards. |
| 8. |
I understand that this Authorization is not required for the Plan to use or disclose any Protected Health Information for purposes of treatment, payment or health care operations, or if the use or disclosure is otherwise permitted by the Privacy Standards, and that any revocation of this Authorization will have no effect on such uses or disclosures. |
| 9. |
I understand that the Plan may not condition my enrollment or eligibility for, or payment of, benefits on my agreeing to this Authorization. I also understand that I am entitled to receive a copy of this Authorization. |
| 10. |
I agree to protect the confidentiality of the password to prevent unauthorized persons from accessing or using my Protected Health Information or the Protected Health Information of the Dependents. If I have reason to believe the password has become known to any unauthorized person, I immediately will notify TPA, so that the password may be changed. |
| 11. |
I release the Plan, the Plan Administrator and TPA from any and all liability that may arise from improper access, use or disclosure of my Protected Health Information by the Dependents or unauthorized persons using the password. |
