AUTHORIZATION TO OBTAIN INFORMATION MAIL TO: Continental American Insurance Company P.O. Box 84075 Columbus, Georgia 31993 CALL: 1.800.433.3036 (toll-free) CLAIM FAX: 1.866.849.2970 Primary Certificateholder’s Name: SSN(optional): Date of Birth: Certificate Number(s): Address: Name of Individual Subject to Disclosure (If not the primary Certificateholder): Date of Birth: Relationship to Primary Certificateholder: □Self □ Spouse □ Domestic Partner □ Child □ Stepchild □ Grandchild I. Authorization: For the purpose of evaluating my eligibility for insurance and for benefits under an existing certificate, including checking for and resolving any issues that may arise regarding incomplete or incorrect information on my application for coverage and/or claim form, I hereby authorize the disclosure of the following information(defined below) about me and, if applicable, my dependents, from the sources listed below to Continental American Insurance Company (CAIC), or any person or entity acting on its part, to include American Family Life Assurance Company of Columbus and American Family Life Assurance Company of New York (collectively, “Aflac). II. Disclosure of Health Information: Health information may be disclosed by any health care provider, health plan (including CAIC or Aflac, with respect to other CAIC or Aflac coverages) or health care clearinghouse that has any records or knowledge about me. Health care provider includes, but is not limited to, any licensed physician, medical or nurse practitioner, nurse, pharmacist, osteopath, psychologist, physical or occupational therapist, chiropractor, dentist, audiologist or speech pathologist, podiatrist, hospital, medical clinic or laboratory, pharmacy, rehabilitation facility, nursing home or extended care facility, prescription drug database or pharmacy benefit manager, or ambulance or other medical transport service. Health information may also be disclosed by any insurance company or the Medical Information Bureau (MIB). Health information includes my entire medical record, but does not include psychotherapy notes. Some information obtained may not be protected by certain federal regulations governing the privacy of health information, but the information is protected by state privacy laws and other applicable laws. CAIC will not disclose the information unless permitted or required by those laws. III. Rights and Expiration: I understand that I may revoke this authorization at any time, except to the extent that CAIC or Aflac has taken action in reliance on this authorization. If I revoke this authorization, CAIC may not be able to evaluate my application for coverage and/or claim. To revoke this authorization, I must provide a written and signed revocation to CAIC at the address or fax number above. Unless otherwise revoked, this authorization shall remain in effect for two (2) years from the date signed or upon my death, whichever occurs first. I agree that a copy of this authorization is as valid as the original and that I or an authorized representative may request a copy of this authorization. IV. Notice: I understand that CAIC is not conditioning payment, enrollment, or eligibility for benefits on whether I sign this authorization. I understand that if the information disclosed is protected health information relating to a health plan and the person or entity receiving the information is a not a health care provider or health plan covered by federal privacy regulations, the information disclosed may be redisclosed by such person or entity and will likely no longer be protected by the federal privacy regulations. • If records are on an adult dependent, (e.g. spouse, child over 18), the dependent must sign this form • If records are on a minor child the natural parent or legal guardian must sign on their behalf. Signature of Individual Subject to Disclosure Date Signed Date Signed Legal Representative’s Printed Name Legal Representative’s Signature Legal Relationship If signed by a legal representative (e.g. Legal Guardian, Estate Administrator, Power of Attorney) AGC06105 CONTINENTAL AMERICAN INSURANCE COMPANY Post Office Box 84075 * Columbus, GA. 31993 Phone (800) 433-3036 * Fax (866) 849-2970