Privacy Rule Authorization

This form is the participant's signed permission to allow a covered entity to discuss or disclose the participant's protected health information (PHI) that is described below for the purpose(s) and to the recipient(s) stated in this Authorization.

Group Name
Group Number
Participant Name Participant Name First Last
Participant Date of Birth Participant Date of Birth / MM / DD YYYY
Participant Last 4 Digits of SS#
Participant Email
Authorization

If you sign this document, you give permission to the below named individual(s) to:

Submit your personal health information (PHI) to BeniComp Select and sign on your behalf in the form of a claim;
Discuss your personal health information submitted to BeniComp Select as a claim;
Access this information using our web-based portal.

The PHI that the authorized individual(s) will be discussing with BeniComp Select includes:

Type of Service
Providers of Service
Dates of Service
Service Expenses
The PHI listed above may be discussed and/or disclosed (released) to: The PHI listed above may be discussed and/or disclosed (released) to: First Last
Click here for multiple indviduals
Name Name First Last
Name Name First Last
The above named individual(s) is required by law to protect your health information. By signing this document, you authorize the individual(s) named above to discuss and/or disclose (release) your health information with BeniComp Select. Those persons who receive your health information may not be required by Federal privacy laws (such as the Privacy Rule) to protect it and may share your information with others without your permission, if permitted by laws governing them. This Authorization does not have an expiration date.

Please note, you may change your mind and revoke (take back) this Authorization at any time. To revoke this Authorization, you must notify BeniComp Select in writing.
Participant Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Signed Date Signed Date / MM / DD YYYY