Authorization for Use of Website and Password
This authorization is provided in accordance with the standards for privacy of individually identifiable health information (the “Privacy Standards”) issued under the Health Insurance Portability and Accountability Act of 1996, as amended (“HIPAA”).
I understand, acknowledge and agree to the following:
As a participant in my group health plan, I hereby authorize the issuance of a password and the use or disclosure of, including access to, my protected health information (as defined in the Privacy Standards) as described in this authorization.
It is my desire that a password be issued so that I may access information regarding my claims under the health plan, as well as those of my dependents, if any. Further, I may wish to disclose this password to the dependents. I recognize that by issuance and use of this password, I am authorizing Elite Administration & Insurance Group, Inc. to disclose to me and my dependents our own protected health information.
The protected health information that may be accessed and disclosed through use of the password includes, with respect to myself and my dependents covered under the health plan, the following:
- Information regarding enrollment in the health plan
- Information regarding claims filed, including date of service, provider of service, amount charged and general description of services rendered.
- Information regarding payment and denial of claims, including the reason for denial of any claims.
I understand that if I make this password available to my dependents, it will allow them to access the information described in Item 3 above and I hereby authorize such access.
This authorization shall expire within ten business days following my termination as a participant in this health plan.
I understand that I have the right to revoke this authorization by delivering a written notice of my desire to revoke this authorization to Elite Administration & Insurance Group, Inc. at 310 South Racine Avenue, Suite 700, Chicago, Illinois 60607, Attention: Privacy Officer. The revocation will be effective within ten business days following Elite’s receipt of my written notice. I understand that I cannot revoke this authorization to the extent that the health plan, or Elite on behalf of the health plan, have taken action in reliance on this authorization (for example, any disclosure made prior to the revocation under this authorization will not be affected by the revocation).
I understand that the information described in Item 3 above, once disclosed to my dependents, may be re-disclosed by those individuals and no longer protected by the Privacy Standards.
I understand that this authorization is not required for the health plan to use or disclose any protected health information for purposes of treatment, payment or health care operations, or if the use or disclosure is otherwise permitted by the Privacy Standards, and that any revocation of this authorization will have no effect on such uses and disclosures.
I understand that the health plan my not condition my enrollment or eligibility for, or payment of, benefits on my agreeing to this authorization. I also understand that I am entitled to receive a copy of this authorization.
I agree to protect the confidentiality of the password to prevent unauthorized persons from accessing or using my or my dependents protected health information.
I release the health plan, the plan administrator and Elite Administration & Insurance Group, Inc. from any and all liability that may arise from improper access, use or disclosure of my protected health information by my dependents or unauthorized persons using the password.
If you do not agree with all of the statements contained in the above authorization, you have the right to exit or disconnect from this website by clicking on the “I DISAGREE” button below. If you choose to remain connected to this website and proceed by clicking on the “I AGREE” button, you hereby implicitly agree to all of the statements contained in the above authorization.