The purpose of this Authorization is to permit TruSpecialty to obtain and release nonpublic personal information about me, the Proposed Insured named above, for the purposes of determining my eligibility for, and obtaining insurance products and services from, one or more of the insurers or other institutions listed below. Any and all records and information regarding diagnosis, testing, treatment and prognosis of my physical or mental condition are to be released. Such records and information to be released may include, but not be limited to, facts about my mental and physical health, drug/alcohol abuse treatment, pharmacy prescriptions, HIV testing and treatment, STD testing and treatment genetic general reputation, mode of living, finances, occupation, driving records and other personal traits.
I authorize any physician or other medical practitioner, any hospital, clinic, or other health-related facility, any medical testing laboratory, any insurer, any state motor vehicle department, my past or current employer(s), the Social Security Administration, and any other organization, institution or person that has information about me to release such information to TruSpecialty and its authorized representatives.
I specifically authorize the companies listed below to receive information from, and to release information to, TruSpecialty. I also specifically authorize TruSpecialty, and the companies listed below to release information about me to their reinsurers, underwriters or other persons or organizations performing business, professional or insurance functions for them. I also authorize the Medical Information Bureau, Inc. (MIB) to release information directly to any company listed below, upon such insurer’s request, provided the insurer is a member of MIB.*
This Authorization shall be effective for two years after the date signed below, unless revoked by me in writing and written notice of the revocation is provided to TruSpecialty. Any action taken in reliance of this Authorization prior to the notice of the revocation shall be valid. I understand that any information that is used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and may no longer be protected under federal or state privacy rules.
I acknowledge and I have read and understand the above and agree that this Authorization was completed prior to my signature. I further agree that this digital Authorization shall have equal standing as a signed paper authorization and can be relied upon by TruSpecialty and/or any third party designated herein.
