- You may give written Authorization to disclose your protected health information (PHI) to anyone that you designate and for any purpose.
- If you wish to authorize a person to receive your PHI, please complete the information below.
- Unless this Authorization form is filled out, PHI will NOT be disclosed to anyone other than the patient.
- An Authorization MUST be filled out for each person you wish to receive your PHI.
- In addition, an Authorization MUST be completed by each of your adult dependents.
- Please note that in most cases an Authorization is NOT required for a parent or legal guardian to receive PHI on a minor child.
Yearly/New Hire Notices
See full benefit summaries for details, exclusions, out of network information, & other coverage. Covered expenses only. This web site is not a legal document. This web site is not a guarantee of coverage, eligibility, or provider status and is designed for informational illustration only. Benefits outlined on this web site are subject to change at any time. Please consult your benefit plan provider(s) or administrator(s) for legal documents regarding your plan and to check coverage and/or eligibility