The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that our insurer or HMO obtain your authorization before it may communicate with us about your personal information.  If you would like us have access to your information, you will need to complete and sign the authorization below.  You are under no obligation to provide an authorization if you do not wish to do so.

I authorize the disclosure of my protected health information as follows:

1. I have asked my brokers, Reeve Conover & Jeff Lindgren, to assist me with the following matter regarding my health coverage.

2. I therefore authorize Reeve Conover and Jeff Lindgren, Conover Consulting and KJ Consulting and its business associates, agents, and contractors to disclose claims information, medical information, and any other information related to this issue to my employer as needed to assist me. This authorization includes the Human Resources Department of my Employer, Officers of my employer as needed, and Reeve Conover and Jeff Lindgren and their agents.

3. I understand that I may revoke this authorization in writing at any time, although my right to revoke will be limited if the entity I have authorized to disclose information has taken action in reliance on my authorization. This revocation must be sent to my Employer in writing by email, fax, or mail.

4. I understand that the insurer or HMO may not condition payment, enrollment, or eligibility for benefits on whether I sign this authorization.

5. I understand that the information disclosed to my employer pursuant to this authorization will no longer be protected by HIPAA and may be redisclosed if necessary for us to defend or maintain a lawsuit or administrative action or if required by law.

Please mark as one year from today