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The form explains HIPAA Privacy Rule compliance, disclosure scope, 24-month validity, rights to revoke, and consequences if the authorization is not signed for benefit payments.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/medical-authorization-release-form/283688/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/medical-authorization-release-form/283688.png","ImageObject",442,249,{"name":42,"@type":43},"Đào","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-22","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",13,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information can be disclosed under this authorization?","Question",{"text":63,"@type":64},"The authorization permits disclosure of the entire medical record and other protected health information, including diagnosis or treatment of HIV infection, sexually transmitted diseases, and mental illness, as well as alcohol, drug, and tobacco use. Psychotherapy notes are excluded.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How long does this authorization remain valid?",{"text":68,"@type":64},"It remains in force for 24 months after the signature date, regardless of the patient’s condition or whether living or deceased.",{"name":70,"@type":61,"acceptedAnswer":71},"Can the authorization be revoked, and what happens if it is not signed?",{"text":72,"@type":64},"Revocation can be requested in writing at any time; it is not effective to the extent providers relied on it or if the company has legal rights related to contesting a claim or policy. If the form is not signed, the company may not be able to make benefit payments.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283688,1789617262,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":80,"read_time":4},1374402968488,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","American Memorial Life Insurance Company  \nP.O. Box 2730  \nRapid City, SD 57709  \nMedical Authorization/ Release Form  \nThis Authorization complies with the HIPAA Privacy Rule.  \nPlease scan and return your completed, signed form to us by  \nEmail: [psdocuments@trustage.com](psdocuments@trustage.com)  \nFax: 1-605-719-0601  \nName of Deceased/Patient Date of Birth  \nPolicy Number(s) of Deceased  \nI, as authorized representative of the deceased, authorize any health plan, physician, medical practitioner, healthcare professional, hospital, clinic, pharmacy benefit manager, pharmacy, Medical Information Bureau, LLC (MIB, LLC), laboratory, medical facility, insurance company, insurance support organization (or any of its members or affiliates), the Veteran’s Administration, the deceased’s employer, consumer reporting agency, or any other healthcare provider that has provided payment, treatment or services to the deceased (collectively, “The Providers”) to disclose the entire medical record and any other protected health information concerning the deceased to American Memorial Life Insurance Company (“the Company”) or its reinsurers, their agents, employees, and representatives. This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This also includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco, but excludes psychotherapy notes.  \nBy my signature below, I acknowledge that any agreements to restrict protected health information do not apply to this authorization and I instruct The Providers to release and disclose the entire medical record without restriction.  \nThis protected health information is to be disclosed under the authorization at my request, as permitted by §164.508 of the privacy regulations issued pursuant to the Health Insurance Portability and Accountability Act (“HIPAA Privacy Rule”).  \nThis authorization shall remain in force for 24 months following the date of my signature below, regardless of my condition and whether living or deceased, and a copy of this authorization is as valid as the original. I understand that I have the right to obtain a copy of this authorization and to revoke this authorization in writing, at any time, by sending a written request for revocation to the Company at Attention: Privacy Task Force, P.O. Box 2730, Rapid City, SD 57709. I understand that a revocation is not effective to the extent that any of The Providers has relied on this authorization or to the extent that the Company has a legal right to contest a claim under an insurance policy or to contest the policy itself. I understand that any information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal regulations governing privacy and confidentiality of health information (such as the HIPAA Privacy Rule). However, the Company will protect the privacy of health information in accordance with other applicable state and/or federal privacy laws and its own privacy policies.  \nI understand that if I refuse to sign this authorization to release the complete medical record, the Company may not be able to make any benefit payments. I acknowledge that I have received a copy of this authorization.  \nSignature of Authorized Representative Date  \nDescription of Authorized Representative’s authority to sign on behalf of deceased:  \n􀂅 Parent of Unemancipated Minor 􀂅 Power of Attorney 􀂅 Legal Guardian 􀂅 Other    \nThis form may be used for business underwritten or administered by American Memorial Life Insurance Company or  \nUnion Security Insurance Company, part of the TruStage Financial Group, Inc.  \nADM7110-WEB 0822","cbCaipxMST4ZaNBW","https://ap.wps.com/l/cbCaipxMST4ZaNBW","pdf",77939,"English","# Medical Authorization/Release Form\n## Covered Information and Providers\n## Disclosures Under HIPAA Privacy Rule\n## Validity, Revocation Rights, and Refusal Consequences\n## Authorized Representative Signature Details","[{\"question\":\"What information can be disclosed under this authorization?\",\"answer\":\"The authorization permits disclosure of the entire medical record and other protected health information, including diagnosis or treatment of HIV infection, sexually transmitted diseases, and mental illness, as well as alcohol, drug, and tobacco use. Psychotherapy notes are excluded.\"},{\"question\":\"How long does this authorization remain valid?\",\"answer\":\"It remains in force for 24 months after the signature date, regardless of the patient’s condition or whether living or deceased.\"},{\"question\":\"Can the authorization be revoked, and what happens if it is not signed?\",\"answer\":\"Revocation can be requested in writing at any time; it is not effective to the extent providers relied on it or if the company has legal rights related to contesting a claim or policy. If the form is not signed, the company may not be able to make benefit payments.\"}]","Medical Authorization - Release Form | PDF"]