Privacy

FORM OF AUTHORIZATION

Authorization for the Use or Disclosure of Protected Health Information
Required by the Health Insurance Portability and Accountability Act,
45 C.F.R. Parts 160 and 164

I hereby voluntarily authorize the disclosure of information from my health record in accordance with this Authorization.
The information is to be disclosed by Association Member Benefits Advisors, LLC (“AMBA”), on behalf of benefit and insurance companies Retired Indiana Public Employees Association (RIPEA) Insurance Trust.
The purpose of the disclosure is to enable RIPEA Insurance Trust to identify those of its members who have purchased benefit programs and insurance coverage through AMBA.
The information to be disclosed is only my name and the fact that I have elected to purchase a benefit or insurance program through AMBA.
If this authorization has not been revoked, it will be in effect until the termination of my insurance or benefit program that was purchased through AMBA, at which time this authorization expires.

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First Name

Last Name

Address 1

Address 2

City

State/Province

Zip/Postal Code

RIPEA Member Number

I understand that:

I may revoke this authorization in writing submitted at any time to RIPEA Insurance Trust (2415 Directors Row, Suite M, Indianapolis, IN 46241), except to the extent that action has been taken in reliance on this authorization;

My treatment, payment, enrollment, or eligibility for benefits may not be conditioned on whether I sign this authorization; and

Information disclosed pursuant to this authorization may be subject to redisclosure by RIPEA Insurance Trust and may no longer be protected by 45 C.F.R. Part 164.