Consent To Release Information

Consent To Release Information
Respecting and protecting your privacy is vital to us, and we take our responsibility to protect the privacy and confidentiality of your information very seriously. By the Trusts’ policies and by law we cannot release your personal information, including your personal health information, to anyone other than you except where it is allowed by law. However, we understand that there may be times when it is more convenient for you to have a trusted family member or friend make inquiries, schedule appointments, or confirm information on your behalf. This Consent to Release Information is optional and designed for you to let us know who you trust with your confidential information.
Your name *

First Name Last Name
Date of Birth *

Month Day Year
Date
City *
Preferred phone number *
Please enter a valid phone number.
*

Cell phone Landline
Person you consent to release information to

Trusted family member or friend who can make inquiries, schedule appointments, or confirm information on your behalf.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Mailing address *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *
Please enter a valid phone number.
Email
example@example.com
Relation to you *
By signing this consent form you are agreeing that the following information may be discussed with the person you have chosen above. This person may:
- Discuss with the Carewell SEIU 503 benefits team, and/or any of the Partners specifically designated below, any information relating to your participation in, and your receipt of Carewell SEIU 503 benefits, including but not limited to, your name, date of birth, Social Security number, income, address, phone number, and email address.
- Discuss with the Carewell SEIU 503 benefits team and/or any of its Partners specifically designated below the details of the insurance policy for which you have applied, or for which you are in the process of applying, through the applicable state or federal Healthcare Marketplace, including but not limited to, coverage lines available to you, name of Insurance Carrier, insurance plan information, payment/billing details, premium amount, and federal premium tax credits available to you (if applicable).
- Set appointments for you with the benefits team or one of its Partners.
This consent form does not allow the person you have named above to:
- Enroll you in coverage, terminate your coverage, or change your coverage selection.
- Sign any documents on your behalf, unless the person has a valid Power of Attorney document giving them this authority and you have provided a copy of such Power of Attorney document to Carewell SEIU 503.
- Speak to the Benefit Convenience Card issuer (Ameriflex), Insurance Carrier, or the Health Insurance Marketplace on your behalf. These entities have their own guidelines for consent that must be followed when speaking with them.
I understand that I am consenting to the release of the information described on this form to the person I have named above. This consent is valid until such time as I contact the Benefits Administrative Office in writing to make changes and/or terminate this consent. I understand I have the right to refuse to sign this form. If signed, I have the right to revoke this authorization, in writing, at any time. I understand I am not required to sign this form to receive my benefits, nor does signing this form alter my enrollment in Carewell SEIU 503 benefits, my eligibility, or any payments I may owe under the Trust(s).
I also understand I am giving consent to RISE partnership, and the following Partners, to speak to the person I have named above: *

Carewell SEIU 503 Benefits Team Benefits Administrative Office (Vimly) Valley Insurance Professionals (VIP) Member Assistance Center
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

Consent To Release Information

Person you consent to release information to