I hereby authorize the use or disclosure of my protected health information as described below:
1. AUTHORIZED PERSONS TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
As licensed insurance agents, Valley Insurance Professionals, Inc. may collect your protected health information through the process of assisting you or your family to apply for health insurance. Valley Insurance Professionals is authorized to disclose the protected health information listed below to RISE Partnership, Carewell SEIU 503 Benefits, the Oregon Homecare Workers Supplemental Trust, the Oregon Homecare Workers Benefit Trust and their providers, and/or any applicable state or federal insurance marketplace or insurance exchange, or insurance company or carrier necessary to apply for, renew or service your insurance coverage.
2. DESCRIPTION OF INFORMATION TO BE DISCLOSED
All information provided on your application for health insurance, whether via website enrollment, direct enrollment, phone enrollment, or on paper, including information on all members of your tax filing household. All past, present, and future periods of health care information (as defined by HIPAA).
3. PURPOSE OF THE USE OR DISCLOSURE
The purpose of this use or disclosure is to assist RISE Partnership, Carewell SEIU 503 Benefits, the Oregon Homecare Workers Supplemental Trust and the Oregon Homecare Workers Benefit Trust in the administration of your benefits under the applicable Trusts.
4. VALIDITY OF AUTHORIZATION FORM
This Authorization Form is valid beginning the date of this Agreement and expires ten years from the date of execution of this Authorization Form.
I understand that the information used or disclosed under this Authorization Form may be subject to re-disclosure by the person(s) or facility receiving it, subject to the federal privacy regulation. I have the right to refuse to sign this Authorization Form. If signed, I have the right to revoke this authorization, in writing, at any time. I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.