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HIPAA All States Text

Authorization for the Release of Medical Information

All States

This authorization complies with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.

I hereby authorize the use or disclosure of health information, as described below, about me or my below-named unemancipated minor children and revoke any previous restrictions concerning access to such information:

  1. Person(s) or group(s) of persons authorized to use and/or disclose the information: Any health plan, physician, health care professional, hospital, clinic, long-term care facility, medical or medically-related facility, laboratory, pharmacy, pharmacy benefit manager, insurance company [including Transamerica Life Insurance Company (“the Company”)], insurance support organization such as MIB, Inc. (“MIB”), or other medical practitioner or health care provider that has provided payment, treatment or services to me or on my behalf or to or on behalf of my unemancipated minor children.

  2. Person(s) or group(s) of persons authorized to collect or otherwise receive and use the information: The Company, its affiliates and reinsurers, and their agents, employees, or other representatives. I further authorize the Company and its affiliates and reinsurers to redisclose the information to MIB.

  3. Description of the information that may be used or disclosed: This authorization specifically includes the release of all information related to my health or that of my unemancipated minor children and my or my unemancipated minor children’s insurance policies and claims, including, but not limited to, information on the diagnoses, prognoses, treatments, prescription drug information, and information regarding diagnosis, prognosis and treatment of mental illness, communicable or infectious conditions, such as HIV or AIDS, and use of alcohol, drugs and tobacco. This Authorization excludes psychotherapy notes that are separated from the rest of my medical records.

  4. The information will be used or disclosed only for the following purpose(s): For the purpose of underwriting my insurance application with the Company and, if a policy is issued, for evaluating contestability and eligibility for benefits, for the continuation or replacement of the policy, for reinstatement of the policy or to contest a claim under the policy.

Statements of Understanding & Acknowledgement:

  • I understand that health information about me provided to the Company may be protected by state and federal privacy regulations including the HIPAA Privacy Rule and that the Company will only use and disclose such information as permitted by applicable regulations and as described in its privacy notices. However, I also understand that any information disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal regulations such as the HIPAA Privacy Rule governing privacy and confidentiality of health information.

  • I understand that if I refuse to sign this authorization to release my health information or that of my unemancipated minor children, the Company may not be able to process my application, or if coverage is issued may not be able to make any benefit payments.

  • I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it, or to the extent that other law provides the Company with the right to contest a claim under the policy or the policy itself, by sending a written revocation to the Company’s Privacy Official at the address at the top of this form. I also understand that the revocation of this authorization will not affect uses and disclosures of my health information for purposes of treatment, payment and business operations, including agent commission statements.

  • This authorization shall remain in force for 24 months (12 months in Kansas) from the date signed, regardless of my condition and whether living or deceased

  • I acknowledge that I have received a copy of this authorization.

HIPAA California Text

Authorization for the Release of Medical Information

California

This authorization complies with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.

I hereby authorize the use or disclosure of health information, as described below, about me or my below-named unemancipated minor children and revoke any previous restrictions concerning access to such information:

  1. Person(s) or group(s) of persons authorized to use and/or disclose the information: Any health plan, physician, health care professional, hospital, clinic, long-term care facility, medical or medically-related facility, laboratory, pharmacy, pharmacy benefit manager, insurance company [including Transamerica Life Insurance Company (“the Company”)], insurance support organization such as MIB, Inc. (“MIB”), or other medical practitioner or health care provider that has provided payment, treatment or services to me or on my behalf or to or on behalf of my unemancipated minor children.

  2. Person(s) or group(s) of persons authorized to collect or otherwise receive and use the information: The Company, its affiliates and reinsurers, and their agents, employees, or other representatives. I further authorize the Company and its affiliates and reinsurers to redisclose the information to MIB.

  3. Description of the information that may be used or disclosed: This authorization specifically includes the release of all information related to my health or that of my unemancipated minor children and my or my unemancipated minor children’s insurance policies and claims, including, but not limited to, information on the diagnoses, prognoses, treatments, prescription drug information, and information regarding diagnosis, prognosis and treatment of mental illness, communicable or infectious conditions, such as HIV or AIDS, and use of alcohol, drugs and tobacco. This Authorization excludes psychotherapy notes that are separated from the rest of my medical records.

  4. The information will be used or disclosed only for the following purpose(s): For the purpose of underwriting my insurance application with the Company and, if a policy is issued, for evaluating contestability and eligibility for benefits, for the continuation or replacement of the policy, for reinstatement of the policy or to contest a claim under the policy.

Statements of Understanding & Acknowledgement:

  • I understand that health information about me provided to the Company may be protected by state and federal privacy regulations including the HIPAA Privacy Rule and that the Company will only use and disclose such information as permitted by applicable regulations and as described in its privacy notices. However, I also understand that any information disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal regulations such as the HIPAA Privacy Rule governing privacy and confidentiality of health information.

  • I understand that if I refuse to sign this authorization to release my health information or that of my unemancipated minor children, the Company may not be able to process my application, or if coverage is issued may not be able to make any benefit payments.

  • I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it, or to the extent that other law provides the Company with the right to contest a claim under the policy or the policy itself, by sending a written revocation to the Company’s Privacy Official at the address at the top of this form. I also understand that the revocation of this authorization will not affect uses and disclosures of my health information for purposes of treatment, payment and business operations, including agent commission statements.

  • This authorization shall remain in force for 24 months from the date signed, regardless of my condition and whether living or deceased.

  • I acknowledge that I have received a copy of this authorization.

HIPAA Maine Text

Authorization for the Release of Medical Information

Maine

This authorization complies with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.

I hereby authorize the use or disclosure of health information, as described below, about me or my below-named unemancipated minor children and revoke any previous restrictions concerning access to such information:

  1. Person(s) or group(s) of persons authorized to use and/or disclose the information: Any health plan, physician, health care professional, hospital, clinic, long-term care facility, medical or medically-related facility, laboratory, pharmacy, pharmacy benefit manager, insurance company [including Transamerica Life Insurance Company (“the Company”)], insurance support organization such as MIB, Inc. (“MIB”), or other medical practitioner or health care provider that has provided payment, treatment or services to me or on my behalf or to or on behalf of my unemancipated minor children.

  2. Person(s) or group(s) of persons authorized to collect or otherwise receive and use the information: The Company, its affiliates and reinsurers, and their agents, employees, or other representatives. I further authorize the Company and its affiliates and reinsurers to redisclose the information to MIB.

  3. Description of the information that may be used or disclosed: This authorization specifically includes the release of all information related to my health or that of my unemancipated minor children and my or my unemancipated minor children’s insurance policies and claims, including but not limited to, information on the diagnoses, prognoses, treatments, prescription drug information, and information regarding diagnosis, prognosis and treatment of mental illness, use of alcohol, drugs and tobacco, communicable or infectious conditions, excluding HIV. This Authorization excludes psychotherapy notes that are separated from the rest of my medical records.

  4. The information will be used or disclosed only for the following purpose(s): For the purpose of underwriting my insurance application with the Company and, if a policy is issued, for evaluating contestability and eligibility for benefits, for the continuation or replacement of the policy.

Statements of Understanding & Acknowledgement:

  • I understand that health information about me provided to the Company may be protected by state and federal privacy regulations including the HIPAA Privacy Rule and that the Company will only use and disclose such information as permitted by applicable regulations and as described in its privacy notices. However, I also understand that any information disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal regulations such as the HIPAA Privacy Rule governing privacy and confidentiality of health information.

  • I understand that if I refuse to sign this authorization to release my health information or that of my unemancipated minor children, the Company may not be able to process my application, or if coverage is issued may not be able to make any benefit payments.

  • I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it, or to the extent that other law provides the Company with the right to contest a claim under the policy or the policy itself, by sending a written revocation to the Company’s Privacy Official at the address at the top of this form. I also understand that the revocation of this authorization will not affect uses and disclosures of my health information for purposes of treatment, payment and business operations, including agent commission statements.

  • This authorization shall remain in force for 24 months from the date signed, regardless of my condition and whether living or deceased.

  • I acknowledge that I have received a copy of this authorization.

HIPAA authorization contact card

HIPAA authorization

Claims Department

Transamerica

PO Box 219

Cedar Rapids, IA 52406-0219

L&A Alabama

Address of insurance department
Alabama Department of Insurance, 201 Monroe Street, Suite 502, Montgomery, AL 36134
Fax
(334) 240-3282
Appointment fee
$30.00

L&A Alaska

Address of insurance department
Alaska Licensing Division, 333 Willoughby Avenue, Juneau, AK 99801
Fax
(907) 465-3422
Appointment fee
N/C

L&A Arizona

Address of insurance department
Arizona Department of Insurance, 2910 N 44th Street, Suite 210, Phoenix, AZ 85018-7269
Fax
(602) 364-4460
Appointment fee
N/C

Filing instructions for Critical Illness Insurance

Submitting your claim online is a lot faster than mailing it and it lets you track the status anytime, anywhere.

When you submit you claim online, sign up for direct deposit --- that's the fastest and safest way to receive any payments you are eligible for.

To do:

  • Fill in all the required and optional (indicated) fields with complete and accurate information

  • If you need help, our Customer Service professionals can be reached Monday through Friday, 7am - 5pm CT, at 888-763-7474

Required Documents:

  • Attending Physician's Statement

    Download this form and have your doctor complete it with all required information.

     
    download
  • Discharge Summary

    The hospital will provide you with a discharge summary report when you are released from the hospital.

  • Diagnostic Report

    Your doctor/hospital will provide you with a diagnostic report.

  • Pathology Report

    Your doctor/hospital will provide you with a pathology report.

  • Date of Diagnosis

    Please provide documentation of your date of diagnosis.

  • Authorization Form

    A signed authorization form is recommended, as some providers will not accept an electronic signature.

 
Need to come back to complete this submission? No problem! You can save the information you have already uploaded and come back later to complete the rest.

Producer Attestation

New York Department of Financial Services (NYDFS) attestation is due 12/31/2024. To complete your attestation, please

Expiration Date

Producer Compliance Resource Placeholder

2283263

Producer Portal Manage Alerts Placeholder

2388370

Producer Portal Manage Users Placeholder

2388371

Resources Producer Text

You may find these producer guides helpful.

Upload Documents Accident

Upload Documents

Please upload the following forms for your Accident claim.

 
If more convenient for you, supporting documents can also be sent by email at sendyourdocs@transamerica.com
  • Attending Physician’s Statement

    DOWNLOAD
  • Itemized Statements of Medical Charges

  • Police Report

    If your claim is related to a motor vehicle accident.

  • Discharge Summary

  • Authorization Form

Product

Upload Documents Cancer

Upload Documents

Please upload the following forms for your Cancer Insurance claim.

 
If more convenient for you, supporting documents can also be sent by email at sendyourdocs@transamerica.com
  • Attending Physician’s Statement

    Not completed yet? Print this Attending Physician's Statement and have your doctor complete it with all required information.

    DOWNLOAD
  • Itemized Statements of Medical Charges

  • Pathology Report

  • Medicare, Medicaid Insurance Statement

  • Ambulance Statement (if applicable)

  • Authorization Form

Product