CSS2HTML: WEB7213.XDP

Form 7213
Revised 9/12/2017
Page 1

S.C. Public Employee Benefit Authority

Attention: Customer Service

202 Arbor Lake Drive

Columbia, SC 29223

PURPOSE OF THIS FORM

This form is used to authorize the South Carolina Public Employee Benefit Authority (PEBA) to share a member's confidential PEBA benefits information with a particular person who acts as the member's Authorized Representative.   

 

 

REQUESTOR'S INFORMATION

AUTHORIZED USE AND/OR DISCLOSURE

Intended Use or Disclosure:

I understand that PEBA's policy is not to disclose my confidential insurance and retirement information to other parties without my written authorization except where permitted or required by law.  For this reason, I authorize PEBA to disclose my confidential insurance and retirement information described above to the person(s) named below, and to authorize PEBA to discuss that information with the person(s) named below, for the purpose of assisting me with my participation in the insurance and retirement plans administered by PEBA.  I also understand that if my Authorized Representative(s) is not another entity subject to applicable state and federal privacy laws, my confidential benefit information may no longer be protected by those privacy laws and that my Authorized Representative may further disclose my confidential information without my authorization.  I acknowledge that my authorization is voluntary. 

Requestor's Name:

SSN:

Address:

Email Address:

Phone Number:

Name:

Phone Number:

Address:

Email Address:

Authorized Representative #1:

Name:

Phone Number:

Address:

Relationship to You:

Authorized Representative #2:

AUTHORIZED REPRESENTATIVE FORM

BIN:

Insurance Policyholder's Name (if different than above):

Policyholder's BIN:

Limitations to Disclosure:

 INFORMATION TO BE DISCLOSED

By signing this form I authorize PEBA to release to my Authorized Representative(s):

A) My personal health information and other insurance information related to my participation in an insurance program administered by PEBA. Personal health information would include, but not be limited to, identification of treating providers of care, personal diagnoses and demographic information (not including psychotherapy notes).  Other insurance information related to my participation in an insurance program administered by PEBA would include, but not be limited to, my insurance elections, premiums, dependents, and claim information.

B) My confidential retirement information related to my participation in any of the retirement plans administered by PEBA.  Confidential retirement information would include, but not be limited to, information in a retirement system administered by PEBA related to my enrollment, beneficiary designations, eligibility for service or disability retirement benefits, and benefit payments and other distributions.

 

LIMITATIONS TO DISCLOSURE

I understand that I have the right to limit the information that PEBA releases under this authorization.  For example, I may limit my Authorized Representative's access to information about a particular health care provider or a particular retirement matter or transaction.  Any such limitations must be set out below in writing.  I understand that by leaving this section blank, I am creating no limitations on disclosure.

Relationship to You:

Email Address: