This Authorization was prepared by First Agency, Inc. for purposes of obtaining information necessary to process a claim for benefits.
Upon presentation of the original or a photocopy of this signed Authorization, I authorize, without restriction(except psychotherapy notes), any licensed physician, medical professional, hospital or other medical-care institution, insurance support organization, pharmacy, governmental agency, insurance company, group policy holder, employer or benefit plan administrator to provide First Agency, Inc. or an agent, attorney,consumer reporting agency or independent administrator, acting on its behalf, all information concerning advice, care or treatment provided the patient, employee or deceased named below, including all information relating to, mental illness, use of drugs or use of alcohol. This Authorization also includes information provided to our health division for underwriting or claim servicing and information provided to any affiliated insurance company on previous applications. If this Authorization is for someone other than myself, that individual has given me the authority to act on his/her behalf as explained below.
I understand that I have the right to revoke this Authorization, in writing, at any time by sending written notification to my agent or to us at the above address. I understand that a revocation will not be effective to the extent we have relied on the use or disclosure of the protected health information or if my Authorization was obtained as a condition to determine my eligibility for benefits. Revocation requests must be sent in writing to the attention of the Claims Supervisor.
I understand that First Agency, Inc. may condition payment of a claim upon my signing this authorization, if the disclosure of information is necessary to determine the level or validity of the claim payment. I also understand, once information is disclosed to us pursuant to this Authorization, the information will remain protected by First Agency, Inc. in accordance with federal or state law.
I understand that I or my authorized representative is entitled to receive a copy of this authorization upon request.
This Authorization is valid from the date signed for the duration of the claim.
Please list the School oR College That Claimant Attends:
Signature of Claimant (if claimant is 18 or older) or Authorized Representative or Next of Kin: