Insurance Family ROI Form

INSURANCE FAMILY ROI FORM

Applicant / Insured Information

Date of Birth:    Policy Number:

Policy Details

Policy Type:    Coverage Amount:

Deductible:    Premium:

Policy Period From:    To:

Family Members Authorized to Receive Information

List family members or designated representatives who are authorized to receive information about the policy, claims, billing, or medical records related to the insured. If authorizing more than four, attach additional pages signed and dated.

Relationship:    DOB:

Relationship:    DOB:

Relationship:    DOB:

Scope of Release (select all that apply)

Policy information (coverage, status, benefits)
Claims information and claim status
Medical records and treatment summaries (limited to claim-related records)
Billing, invoices, and payment history
Premium payment arrangements and payment details
Other:

Duration, Revocation, and Limitations

Effective Date:    Expiration Date:

Revocation: This authorization may be revoked at any time by written notice signed by the applicant and delivered to the insurer at the address provided above. Revocation will not affect disclosures made prior to receipt of the revocation. The insurer may continue to rely on disclosures made pursuant to this authorization if made in good faith prior to the insurer's receipt and processing of a valid revocation.

Exclusions and Special Instructions

Beneficiary Information (if applicable)

Provide primary beneficiaries for policies where beneficiary designation is relevant. Percentages must total 100% for primary beneficiaries listed.

Relationship:    Percentage: %

Relationship:    Percentage: %

Documentation Checklist (for claims / inquiries)

Government-issued ID of requester
Copy of policy or proof of relationship to insured
Claim number and related documentation
Medical records release form (if medical records requested)

Declaration and Certification

I hereby authorize the release of the information described above to the individuals named in this form. I understand that information disclosed pursuant to this authorization may include sensitive personal information and that such information may be subject to privacy protections under applicable law. I certify that I am the insured or an authorized representative of the insured and that the information provided on this form is true and correct to the best of my knowledge. I understand that this authorization is voluntary and that I may revoke it in writing as specified above, except to the extent that action has already been taken in reliance on it.

Relationship to insured (if not insured):

Contact for Applicant

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