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AUTHORIZATION FORM FOR DISCLOSURE OF A CONSUMER’S
PROTECTED HEALTH INFORMATION FOR MARKETING PURPOSES
(“Authorization”)
1. I hereby authorize the use and disclosure of my protected personally identifiable health information contained in the Company’s
records (“Protected Health Information”) to American Retirement Life Insurance Company, Loyal American Life Insurance
Company®, Cigna Health and Life Insurance Company, and their affiliates (“Company”) as described below.
2. I authorize the Company to use the Protected Health Information contained in the Company’s records, including its underwriting
and claim records, to help determine whether I might be interested in or can benefit from other non-health-related insurance
products offered by the Company.
3. I understand that the Company will disclose the Protected Health Information to its underwriting staff, new business staff, sales
agents, or marketing management for the purpose of marketing non-health-related products to me.
4. I understand that I may revoke this Authorization at any time, except to the extent that action has been taken by the Company
in reliance on this Authorization, by sending a written revocation to the Company’s Privacy Steward at PO Box 26580, Austin,
Texas 78755-0580.
5. I understand that the Protected Health Information which the Company will use and disclose under this Authorization is not
necessary for the Company to determine my eligibility for coverage under the policy and that the Company will not condition
its approval and issuance of the policy on my providing this Authorization.
6. I understand that if the person or entity that receives my Protected Health Information is not a health care provider or health
plan covered by the federal privacy regulations, the information may be redisclosed by such person or entity and will likely no
longer be protected by the federal privacy regulations.
7. I understand that a photocopy, facsimile copy, or other electronic copy of this Authorization is as effective and valid as
the original. I also understand that I or my personal representative am entitled to receive a copy of this Authorization. This
Authorization will expire twenty-four (24) months from the date it is signed.
If you are the representative of a Consumer, describe the scope of your authority to act on the Consumer’s behalf:
____________________________________________________________________________________________________________
____________________________________________________ ____________________________________________________
Consumer’s Name Name of Consumer’s Personal Representative, if applicable
____________________________________________________ ____________________________________________________
Relationship of Personal Representative to the Consumer
Signature of Consumer Date
__________________________________________________ ____________________________________________________
Signature of Company’s Agent Date Signature of Personal Representative Date
A signed copy of this form will be provided to you.
HIPAA-MKT-CS-FL (08-17)
PROTECTED HEALTH INFORMATION FOR MARKETING PURPOSES
(“Authorization”)
1. I hereby authorize the use and disclosure of my protected personally identifiable health information contained in the Company’s
records (“Protected Health Information”) to American Retirement Life Insurance Company, Loyal American Life Insurance
Company®, Cigna Health and Life Insurance Company, and their affiliates (“Company”) as described below.
2. I authorize the Company to use the Protected Health Information contained in the Company’s records, including its underwriting
and claim records, to help determine whether I might be interested in or can benefit from other non-health-related insurance
products offered by the Company.
3. I understand that the Company will disclose the Protected Health Information to its underwriting staff, new business staff, sales
agents, or marketing management for the purpose of marketing non-health-related products to me.
4. I understand that I may revoke this Authorization at any time, except to the extent that action has been taken by the Company
in reliance on this Authorization, by sending a written revocation to the Company’s Privacy Steward at PO Box 26580, Austin,
Texas 78755-0580.
5. I understand that the Protected Health Information which the Company will use and disclose under this Authorization is not
necessary for the Company to determine my eligibility for coverage under the policy and that the Company will not condition
its approval and issuance of the policy on my providing this Authorization.
6. I understand that if the person or entity that receives my Protected Health Information is not a health care provider or health
plan covered by the federal privacy regulations, the information may be redisclosed by such person or entity and will likely no
longer be protected by the federal privacy regulations.
7. I understand that a photocopy, facsimile copy, or other electronic copy of this Authorization is as effective and valid as
the original. I also understand that I or my personal representative am entitled to receive a copy of this Authorization. This
Authorization will expire twenty-four (24) months from the date it is signed.
If you are the representative of a Consumer, describe the scope of your authority to act on the Consumer’s behalf:
____________________________________________________________________________________________________________
____________________________________________________ ____________________________________________________
Consumer’s Name Name of Consumer’s Personal Representative, if applicable
____________________________________________________ ____________________________________________________
Relationship of Personal Representative to the Consumer
Signature of Consumer Date
__________________________________________________ ____________________________________________________
Signature of Company’s Agent Date Signature of Personal Representative Date
A signed copy of this form will be provided to you.
HIPAA-MKT-CS-FL (08-17)
