___________________ CONSENT TO OBTAIN AND RELEASE
NONPUBLIC PERSONAL, FINANCIAL AND MEDICAL INFORMATION
I, __________________, an individual residing at _______________________, do hereby give consent to Zurich American Insurance Company and companies shown below, and its employees and agents who will perform risk management, claim adjustment or administration (collectively, “Zurich”), to obtain disclose, release, or make use of certain personal or privileged information about me on the following terms and conditions:
1. Zurich will have complete and unrestricted rights to OBTAIN, disclose, release, or make use of personal or privileged information about me which may include financial and wage statements, and all medical records, hospital records, reports, charts, notes, histories, laboratory records and reports, diagnostic test reports, doctors’ and nurses’ notes, correspondence, and all other material, including x-ray films, MRI’s, CT’s and EMG/NCS and charges for all care, treatment and prognosis at any and all times for any condition whatsoever for the purpose of risk management, claim adjustment or administration. Those who may RELEASE this information, to the extent permitted by applicable law, to Zurich include health care providers, government agencies, other insurance companies, insurance data base operators, third party administrators or managed care companies their agents or contractors.
2. This Consent will be governed by and construed in accordance with the laws of the State of ______________, without regard to its conflicts of law provisions. This Consent is valid for no more than 24 months from the date executed or until my claim is concluded, whichever occurs earlier.
3. I understand and agree that a photocopy or electronic reproduction of this Consent will be furnished to me and/or my legal or authorized representative upon request.
4. I understand and agree that I can revoke my consent at any time in writing and that doing so may affect my claim. Unless I do so, my permission for Zurich to obtain, receive, use and share my medical information continues until the expiration date referenced in section 2.
5. I understand that upon my request Zurich will provide me with information about my privacy rights afforded me by applicable state or federal law.
6. A copy of this Consent is as valid as the original.
7. This information is for the sole use of the designated persons and/or entities listed above. Unless required by applicable law or court order, this information will not be given in any identifiable form to any other unauthorized person or entity unless I agree to its release in writing.
8. I hereby waive any claim, now or in the future, against Zurich arising out of the disclosure, release, or use of any personal or privileged information about me under the terms of this Consent, including, but not limited to, any claim of a violation of my right to privacy.
9. By separately signing this paragraph, I hereby also consent to the release of any and all wage and financial statements reasonably necessary to adjust my claim.
Signed:
Authorizing Claimant Signature
I have read the above and fully understand its contents in its entirety and have asked questions about anything that was not clear to me and am satisfied with the answers I have received.
I understand, also, that by executing this consent that it is not a release of a claim for damages.
Signature*
Print Name
Signed this __ day of , 200_.
*If an authorized legal representative of the claimant executed this Consent, attach a copy of the authorization.
Please be advised that pursuant to the health insurance portability and accountability act of 1996 ("HIPAA"), zurich is not required to obtain your consent to use your health information for treatment, payment OR health care operations. this document is required by the state of Illinois and should not be CONSIDERED a consent or authorization UNDER hipaa. zurich also reserves any and all rights it has pursuant to hipaa to THE use and/or disclosure of your health information for treatment, payment and health care operations.
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