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Legacy Household Members
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Who is the secondary beneficiary?
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We are on test phase using sandbox account, won't charge you anything.
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In order to determine your eligibility for insurance from Senior Life Insurance Company and process your claims, we need your agreement on the following HIPAA authorization. You are not required to sign this authorization, but without it, Senior Life’s underwriters cannot process your application. Do you authorize any health care provider, plan, or clearinghouse, insurance company, pharmacy, pharmacy benefit manager, Medicare or Medicaid agencies or the Medical Information Bureau, or Consumer Reporting Agency to disclose to Senior Life all your medical records, and including information on medical consultations, treatments, surgeries, or hospital confinements for physical and mental conditions, use of drugs, alcohol, or tobacco, prescription drugs, communicable disease such as HIV or AIDS, but excludes psychotherapy notes? This information will be used by Senior Life to determine your eligibility for insurance and administer your coverage. Other entities to which this information may be disclosed may not be covered by federal privacy rules and if this information is re-disclosed, it may no longer be protected by those rules. This authorization will expire in 24 months. A copy of this authorization shall be as valid as the original. You are entitled to receive a copy of this authorization. You may revoke this authorization at any time by sending written notice to Senior Life but any action taken in reliance on this authorization cannot be reversed. By verbally or physically signing this application I hereby sign and agree to the HIPAA authorization.