Expiration Date or Condition Voiding Authorization
Full Name of Individual Authorized to Release Information
Relationship to TDP Enrollee
Select One Self Custodial Parent Legal Guardian
I understand that I may revoke this authorization at any time by sending a written notice of my revocation to:
United Concordia Companies, Inc.
TDP Customer Service
PO Box 69450
Harrisburg, PA 17106
I understand that revocation of this authorization will not affect any action UCCI or its subsidiaries, affiliates, business associates, etc. took in reliance on this authorization before it received my written notice of revocation. I also understand that without my written authorization, UCCI may not use or disclose my health information for any reason except those described in UCCI’s Notice of Privacy Policies and Practices. Unless otherwise revoked, this authorization will expire on the above date, event or circumstance.
I understand that authorizing the disclosure of this health information is voluntary, and that I can refuse to sign this authorization.
I understand that, if the persons or organizations I authorize to receive and/or use the protected health information described above are not health plans, covered health care providers or health care clearinghouses subject to federal health information privacy laws, they may further disclose the protected health information and it may no longer be protected by federal health information privacy laws.
I release UCCI, its affiliated companies, employees, officers and business associates from legal liability for any recipient’s use or disclosure of information released by UCCI in reliance on this authorization.
Authorized signature of member or personal representative *
Signature Date: 05/18/2021
* I acknowledge and agree that by selecting this box I am
electronically signing this document and intend for it to be my legal
signature. I represent that I am authorized to sign this document and
that all information provided is correct to the best of my knowledge.