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SECRECY ACT |
| The Individual application to which this Individual Application Authorization for Use and Disclosure of Protected Health Information form supersedes any authorization contained on the Individual Application. Federal privacy laws require health plans to include certain provisions in any authorization for use or disclosure of medical information, other than uses or disclosures for treatment, payment, healthcare operations and as required or expressly permitted by law. If Medical Savings Accounts/Health Savings Account Inc. (HSA/MSA) needs to use, disclose or receive health information other than for the purposes set forth herein, we, understand we may be required to sign an authorization which complies with federal law and which is different from this authorization.
On behalf of ourselves and the family member(s) listed on the application, we authorize any physician, health care provider, hospital, insurance or reinsurance company or other insurance exchange to disclose to MSA/HSA, Inc. or its representatives our health information (excluding alcohol, chemical dependency, mental treatment, genetic testing or HIV treatment). We acknowledge and understand that this information will only be used for the purpose of determining enrollment in the health plan, eligibility for benefits of payment of claims. Health information may include claims records, correspondence, medical records, billing statements, diagnostic imaging reports, laboratory reports, dental records or hospital records (including nursing records and progress notes). If we choose not to sign this authorization, MSA/HSA, Inc. may be unable to enroll us in its health plan or to pay claims that were incurred while we had insurance coverage with MSA/HSA, Inc.. We understand that we may cancel this authorization at any time by sending a written request to MSA/HSA, Inc. Our cancellation of this authorization will not affect any action MSA/HSA, Inc. took before it received our request. If we do not revoke this authorization, it will automatically expire upon termination of our coverage with MSA/HSA, Inc. or 24 months from the date below, whichever comes first. Federal law requires MSA/HSA. Inc. to tell us that if the party to whom MSA/HSA, Inc. discloses my personal information shares it with anyone else, some state and federal laws may no longer protect it. This excludes alcohol and drug abuse records, which are protected by federal confidentially rules (42 CFR part 2). Federal law prohibits re-disclosure of this information without specific written authorization. |