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AUTHORIZATION FORM FOR DISCLOSURE OF
AN APPLICANT’S PROTECTED HEALTH INFORMATION
I hereby authorize the disclosure of protected health information about me as described below.
1. The Company, as used in this authorization, shall mean American Retirement Life Insurance Company®; or Central Reserve Life
Insurance Company; or Loyal American Life Insurance Company®; or Provident American Life & Health Insurance Company.
2. I authorize any licensed physician, medical practitioner, hospital, clinic, Pharmacy Benefit Manager, or other medical or medi-
cally-related facility, the U. S. Veterans Administration and Selective Service System, insurance company, MIB, Inc., or any other
organization, institution, or person that has any records or information available as to the diagnosis, treatment, and prognosis
with respect to any physical or mental condition and/or treatment relating to me or my family to disclose to the Company’s
underwriting, new business, claims, sales agents, and premium accounting representatives any such records or information.
3. The protected health information described above will be disclosed to the Company to determine my or my family’s eligibility to
obtain coverage under the policy for which I/we have applied, and to determine the rates and terms which apply to the policy.
4. I understand that I may revoke this authorization in writing 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 Office at
PO Box 26580, Austin, Texas 78755-0580.
5. I understand that the information which will be provided under this authorization is necessary for the Company to determine
my eligibility for coverage under the policy and that the Company will condition its approval and issuance of the policy on my
providing this authorization, and my application may be denied if I refuse to provide 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 re-disclosed 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 shall be considered 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
upon request. This authorization will expire twenty-four (24) months from the date it is signed.
8. If you are the representative of an Applicant, describe the scope of your authority to act on the Applicant’s behalf:
________________________________________________________________________________________________________
____________________________________________________ ____________________________________________________
Applicant’s Name Name of Applicant’s Personal Representative, if applicable
____________________________________________________ ____________________________________________________
Applicant’s Social Security Number Relationship of Personal Representative to the Applicant
__________________________________________________ ____________________________________________________
Signature of Applicant Date Signature of Personal Representative Date
__________________________________________________
Signature of Company’s Agent Date
A signed copy of this form will be provided with the policy if issued and any other time upon request.
HIPAA 0048.1 RETURN TO COMPANY (12-01-12)
AN APPLICANT’S PROTECTED HEALTH INFORMATION
I hereby authorize the disclosure of protected health information about me as described below.
1. The Company, as used in this authorization, shall mean American Retirement Life Insurance Company®; or Central Reserve Life
Insurance Company; or Loyal American Life Insurance Company®; or Provident American Life & Health Insurance Company.
2. I authorize any licensed physician, medical practitioner, hospital, clinic, Pharmacy Benefit Manager, or other medical or medi-
cally-related facility, the U. S. Veterans Administration and Selective Service System, insurance company, MIB, Inc., or any other
organization, institution, or person that has any records or information available as to the diagnosis, treatment, and prognosis
with respect to any physical or mental condition and/or treatment relating to me or my family to disclose to the Company’s
underwriting, new business, claims, sales agents, and premium accounting representatives any such records or information.
3. The protected health information described above will be disclosed to the Company to determine my or my family’s eligibility to
obtain coverage under the policy for which I/we have applied, and to determine the rates and terms which apply to the policy.
4. I understand that I may revoke this authorization in writing 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 Office at
PO Box 26580, Austin, Texas 78755-0580.
5. I understand that the information which will be provided under this authorization is necessary for the Company to determine
my eligibility for coverage under the policy and that the Company will condition its approval and issuance of the policy on my
providing this authorization, and my application may be denied if I refuse to provide 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 re-disclosed 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 shall be considered 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
upon request. This authorization will expire twenty-four (24) months from the date it is signed.
8. If you are the representative of an Applicant, describe the scope of your authority to act on the Applicant’s behalf:
________________________________________________________________________________________________________
____________________________________________________ ____________________________________________________
Applicant’s Name Name of Applicant’s Personal Representative, if applicable
____________________________________________________ ____________________________________________________
Applicant’s Social Security Number Relationship of Personal Representative to the Applicant
__________________________________________________ ____________________________________________________
Signature of Applicant Date Signature of Personal Representative Date
__________________________________________________
Signature of Company’s Agent Date
A signed copy of this form will be provided with the policy if issued and any other time upon request.
HIPAA 0048.1 RETURN TO COMPANY (12-01-12)
