HIPAA Authorization For Release Of Medical Information
Please read and eSign at the bottom.
I authorize any health plan, physician, healthcare professional, hospital, clinic, laboratory, holders of prescription
information on me, including but not limited to, pharmacies, pharmacy benefits managers, and insurers, medical
facility, or other healthcare professional that has provided payment, treatment or services to me or on my behalf
(“My Providers”) to disclose my entire medical record, prescription history, medications prescribed, eligibility,
prescribing physician, pharmacy information, insurance coverage information and any other protected health
information concerning me to Protective Life Insurance Company (the Company). This includes information on the diagnosis or
treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This also includes information
on the diagnosis and treatment of mental illness and the use of alcohol, drugs and tobacco.
By my signature below, l acknowledge that any agreements l have made to restrict my protected health information
do not apply to this authorization and l instruct any physician, healthcare professional, hospital, clinic, medical facility,
or other healthcare provider to release and disclose my entire medical record without restriction.
This protected health information is to be disclosed under this Authorization so that Protective Life Insurance
Company may: 1) evaluate my application for insurance coverage or claims benefits, determine eligibility and risk rating;
2) obtain reinsurance; 3) administer coverage and claims; 4) conduct other legally permissible activities that relate to
any coverage I have or have applied for with Protective Life Insurance Company.
This authorization shall remain in force for 30 months following the date of my signature below and a copy of this
authorization is as valid as the original. l understand that l have the right to revoke this authorization in writing, at any
time, by providing written notification to the entity identified above. I understand that a revocation is not effective to
the extent that any of “My Providers” have already relied on this Authorization to disclose information about me or to
the extent that Protective Life Insurance Company has a legal right to contest a claim under an insurance policy or to contest
the policy itself. l understand that any information that is disclosed pursuant to this authorization is no longer covered by
federal rules governing privacy and confidentiality of health information, but will not be re-disclosed by Protective Life Insurance
Company except as authorized by me or as required by law.
I understand that my providers may not refuse to provide treatment or payment for health care services if I refuse to sign
this Authorization. I further understand that if I refuse to sign the Authorization to release my complete medical record,
Protective Life Insurance Company may not be able to process my application, or if coverage has been issued, may not be able
to make any benefit payments.
Member Legal First Name
Date Signed: 05/24/2022 1:42 AM