HIPAA Authorization for Use and Disclosure of Information

I hereby authorize the use and/or disclosure of my individually identifiable health information (the “Information”) as follows:

In connection with the insurance claim on the accompanying Proof of Loss Form (the “Claim”), I authorize my health care providers to disclose to Summit America Insurance Services, d/b/a Ascension Benefits & Insurance Solutions, my sponsoring college or university, my named parent(s) or guardian(s) and/or any insurance companies to whom the Claim may be submitted (a “Payor”), all Information related to the Claim, for the specific purposes of facilitating the processing and/or payment of the Claim by Ascension Benefits & Insurance Solutions and communicating with Ascension Benefits & Insurance Solutions and the Payor about the Claim.

This authorization is specifically limited to the individually identifiable health information related to the Claim.

I further understand and agree:

1. This authorization will expire upon the termination of the insurance policy between my sponsoring college or university and the Payor.

2. I may revoke this authorization at any time by notifying Ascension Benefits & Insurance Solutions in writing (although the revocation will not have any effect on any actions taken before receiving the revocation).

3. I may see and copy the information described on this form if I ask for it.

4. I am not required to sign this form in order to receive health care services from my provider.

5. The information that is used or disclosed under this authorization may be re-disclosed by the receiving entities, but only for the specific purposes authorized.

If I am signing this Authorization as a Claimant’s Representative, I certify that I have the authority to act on behalf of the Claimant and that the information provided below to verify my identity is correct.

Date: __________________  (Leave blank, date will be added to form if accident takes place.)