Transcription of Transamerica Premier Life Insurance Company …
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Transamerica Premier life Insurance Company 4333 Edgewood Road NE, Cedar Rapids, IA 52499 HIPAA Authorization for Release of Health- Related Information This authorization complies with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. Name of Primary Proposed Insured/Patient Date of birth Last four digits of SSN. _____ _____ _____. Name of Secondary Proposed Insured/Patient Date of birth Last four digits of SSN. _____ _____ _____. Name(s) of Unemancipated Minors Date(s) of birth Last four digits of SSN(s). _____ _____ _____. I hereby authorize the use or disclosure of health information, as described below, about me or my above-named unemancipated minor children and revoke any previous restrictions concerning access to such information: 1.
Transamerica Premier Life Insurance Company 4333 Edgewood Road NE, Cedar Rapids, IA 52499 This authorization complies with the Health Insurance Portability and ...
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