• No results found

Greek Catholic Union of the U.S.A Tuscarawas Road, Beaver, PA Phone: FAX: Authorization

N/A
N/A
Protected

Academic year: 2021

Share "Greek Catholic Union of the U.S.A Tuscarawas Road, Beaver, PA Phone: FAX: Authorization"

Copied!
8
0
0

Loading.... (view fulltext now)

Full text

(1)
(2)
(3)
(4)
(5)

Greek Catholic Union of the U.S.A.

—A Fraternal Benefit Society—

5400 Tuscarawas Road, Beaver, PA 15009 Phone: 724-495-3400 FAX: 724-495-3421

GCUBloodAuth092011

Authorization

For Blood Testing and Disclosure of Results

I do hereby authorize blood to be drawn from me for laboratory tests. I understand that:

1. The tests performed will be those required by the Insurer to determine my eligibility for the insurance I have applied for;

2. I have the right to refuse to have blood drawn and that, in such event, the Insurer will decline to accept my application; and

3. The tests preformed shall include, but are not limited to, tests for:

a. Cholesterol and related blood lipids; glucose; liver or kidney disorder; or the presence of medication, drugs, nicotine or metabolites; and

b. Immune disorders; or T-Helper to T-Suppressor ratio with total T-cell count. I further authorize:

1. The laboratory to disclose the test results to the Insurer;

2. The Insurer to disclosed the test results, including any abnormal results, to its reinsurer, provided such reinsurer is involved in the determination of my eligibility for insurance; and

3. The Insurer to make a brief, coded report to the Medical Information Bureau (MIB) in the manner described in the MIB Notice I received as a part of my application process.

I understand that the test results will be confidential. No one will have access the test results except: as I have authorized; as I may later authorize; or, as may be required by law.

Name of Proposed Insured (Please Print) ____________________________________________ Address________________________________________________________________________ ______________________________________________________________________________ Signature of Proposed Insured_____________________________________________________

Witness________________________________ _____________________________________

(Signature) (Printed Name)

Date_____________________

(6)

GREEK CATHOLIC UNION OF THE USA

(Herein called GCU)

5400 Tuscarawas Road, Beaver, PA 15009-9513 (724) 495-3400

A Fraternal Benefit Society

Addendum to Life Insurance Application Form AL-0494

A. The following questions are added as an addendum to the application form noted above and are part of the application:

1. Does any person named as Beneficiary or Contingent Beneficiary lack an insurable interest* in the person to be insured?

Yes ___ No ___ If yes, please explain ___________________________________ 2. Is any portion of the premium on the policy applied for, to be paid in whole or in part through an assumption; and/or forgiveness of a loan used to fund premiums?

Yes ___ No ___ If yes, please explain ___________________________________

*Insurable interest -A connection by blood of the beneficiary to the insured or an economic connection under which the beneficiary stands to suffer financial loss by reason the death of the insured.

B. Greek Catholic Union of the USA is licensed to do business in the state of Ohio. As a tax exempt entity, Fraternal Benefit Societies are not included in the Ohio Guaranty Association. This means that Fraternal Benefit Societies cannot be assessed for the insolvency of other life insurers or other Fraternal Benefit Societies. By law, a Fraternal Benefit Society is responsible for its own solvency. If there is an impairment of reserves, a certificate holder may be assessed a proportional share of the impairment. This process is described in the certificates issued by the Society.

C. Those portions of the “Notice to Proposed Insured” and/or the authorization on application, Form AL-0494 which make reference to “Medical Information Bureau or MIB” are deleted in their entirety and replaced with the following wording which will amend part of the application Form AL-0494 through inclusion as part of amendment STOLI-2.

Notice to Proposed Insured: I understand that information regarding insurability will be treated as confidential. The Greek Catholic Union of the USA or its reinsurer(s), may,

however make a brief report thereon to MIB, Inc., a not for profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. Should I apply to another MIB member company for life or health insurance coverage or a claim for benefits is submitted to such a company, MIB, upon request, will supply such company with the information it may have about you in its files. The Greek Catholic

STOLI-2 Page 1

(7)

Union of the USA or its reinsurer(s) may also release information in its file to other insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted.

Upon receipt of a request from you, MIB will arrange disclosure of any information in your file. (Medical information will be disclosed to my attending physician only). If you question accuracy of the information in the MIB’s file, you may contact MIB and seek a correction in accordance with the procedures set forth in the Federal Fair Credit

Reporting Act. The address of MIB’s information office is: 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts 02184-8734.

D. I hereby authorize any licensed physician, medical practitioner, hospital, clinic or medical or medically related facility, insurance company, MIB Inc., (“MIB”) or other organization, institution or person, that has any records or knowledge of me or my health, to give the Greek Catholic Union of the USA, or its representatives, including Equifax or bearer, or reinsurer, any such information. The Greek Catholic Union of the USA may disclose such information to its reinsurer(s) or MIB, Inc. This authorization is valid for 30 months after the date shown below.

Signed at __________________________ this ______ day of ___________, 20____

Signature of Proposed Insured Signature of Owner (Parent or Guardian)

STOLI-2 Page 2

(8)

AUTHORIZATION TO OBTAIN, RELEASE AND DISCLOSE MEDICAL INFORMATION

I hereby authorize any: medical practitioner, physician, hospital, clinic, pharmacy benefit manager, or other medical related facility, insurance company, insurance support organization, business partner, pharmacy, government agency, group policy holder, employer, benefit plan administration, the MIB, Inc., the Department of Motor Vehicle Registration, and paramedical facility to provide to THE GREEK CATHOLIC UNION OF THE U.S.A. (GCU), or to any agent, attorney, consumer reporting agency or independent administration, including medical record retrieval services or pharmaceutical services, acting on THE GREEK CATHOLIC UNION OF THE U.S.A. (GCU), or its reinsurers’ behalf, information concerning advice, care, or treatment sought by or provided to me and/or any other applicant for coverage, including information relating to medical history, medical conditions, treatment, hospitalizations or confinements, ailments, pharmacy prescription drugs, and/or drug, alcohol or tobacco usage of the applicant(s) THE GREEK CATHOLIC UNION OF THE U.S.A. (GCU). It is understood that THE GREEK CATHOLIC UNION OF THE U.S.A. (GCU) underwriters, claim examiners, reinsurers, attorneys, or the medical director may disclose such health information to the aforementioned parties for examiners, reinsurers, attorneys, or the medical director may disclose such health information to the aforementioned parties for purposes of underwriting, compliance, record clarification or explanation, or in response to litigation, summons, or subpoenas. I understand that after this information is disclosed, the recipient may re-disclose it resulting in loss of protection by federal regulations.

I understand that:

such information will be used by THE GREEK CATHOLIC UNION OF THE U.S.A. (GCU) for underwriting and insurability determinations;

I may refuse to sign this authorization and that my refusal to sign will affect my ability to obtain life insurance coverage;

A picture copy or photocopy of this authorization shall be as valid as the original; and

Any authorized representative of the proposed insured is entitled to receive a copy of this authorization upon request.

This authorization is valid from the date signed for a duration of 24 months. I understand I may revoke the authorization at any time, except to the extent that action has been taken in reliance on this authorization, by sending written notice to the Life Underwriting Department of THE GREEK CATHOLIC UNION OF THE U.S.A. (GCU), 5400 Tuscarawas Road, Beaver, PA 15009. I may inspect or copy any information used or disclosed under this authorization, if signed.

________________________________________ Date

________________________________________ ________________________________________________________ Proposed Insured (Please print) Signature of Proposed Insured (or parent if Proposed Insured is

under age 18)

__________________________________________________ Birthdate

________________________________________ ________________________________________________________ Additional Proposed Insured (Please print) Signature of Additional Person Proposed for Insurance

________________________________________________________ Birthdate

________________________________________________________ Personal Representative designated by signature above is hereby authorized to execute this instrument based on:

Power of attorney, guardian-in-fact, guardian, payee, representative, other _____________________ (Circle one)

HIPPA A-2013-07-15

References

Related documents

I authorize any licensed physician, medical practitioner, hospital, clinic or other medically related facility, insurance company, agency conducting investigative consumer reports

I hereby authorize any: physician, medical practitioner, hospital, clinic or other medical related facility, insurance company, insurance support organization, business

I hereby authorize any licensed physician, medical practitioner, hospital, clinic, or other medical or medically related facility, insurance company, the Medical Information Bureau,

I authorize any physician, medical practitioner, hospital, clinic, other medical or medically-related facility, insurance company or other organization, institution or person that

Authorization to Release Information: I authorize any licensed physician, medical practitioner, hospital, clinic, or other medical or medically related facility, insurance company

I, by signing below, hereby authorize any licensed physician, medical practitioner, hospital, pharmacy, clinic or other medically-related facility, insurance company, the group

Relative to the insurance applied for, I/we, the person(s) to be insured, hereby authorize any licensed physician, medical practitioner, hospital, pharmacy, clinic or other

I certify that the above is true and complete and I hereby authorize any physician, medical practitioner, hospital, clinic or other medically related facility, insurance company,