- This authorization grants your consent to use or disclose your protected health information so that we may use it to find and craft an insurance policy that's tailored to meet your needs. Click here to return to the main disclosures.
I authorize any physician, health plan, medical practitioner, medical care provider, psychologist, chiropractor, physical therapist, hospital, nursing home, mental health facility, rehabilitation or ambulatory care center, medical clinic, laboratory, pharmacy, Pharmacy Benefit Manager, treatment facility, insurer, insurance support organization, service provider, Kaiser Permanente, financial institution, consumer credit reporting agency, certified public accountants and tax preparers, educational institution, Federal, State, or Local Governmental Agency, including the Social Security Administration, Veterans Administration, or Workers Compensation Board, an authorized medical officer of a United States Government facility, law enforcement agencies, state and local tax agencies, or other medical or medically related facility, specifically including those persons/organizations listed above, to give or disclose my entire medical record and any other protected health information, or other personal, private, or privileged information concerning me for the past 10 years to Ethos Technologies Inc., its agents, insurance carriers, employees, vendors or representatives. I authorize the disclosure of any and all records and information regarding diagnosis, testing, treatment, and prognosis of my physical or mental condition are to be released. This includes information on the diagnosis or treatment of mental illness; the use of alcohol, drugs, and tobacco; and any genetic information or genetic testing results. THIS AUTHORIZATION EXCLUDES the release of any information relating to previously-administered tests for HIV Antibodies, T-Cell Counts, AIDS or ARC by the applicant's/proposed insured's family physician, attending physician, regular doctor, medical practitioner, care giver, insurance company, clinic, health care provider, consumer reporting agency or any other person or entity which may be possessed of such information. The applicant/proposed insured is NOT AUTHORIZING the insurer to release or forward the test results from any new test requested of the applicant or proposed insured by the insurer to any outside, non-affiliated company nor to any person or entity not under specific contract with the insurer to perform underwriting services in connection with this application. This includes information on the diagnosis of sexually transmitted diseases other than HIV. This also includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco.
I authorize MIB, Inc., and any MIB member insurer, to provide any medical or personal information that it has about me to Ethos Technologies Inc., its carriers, reinsurer(s), or any MIB-authorized third-party administrator performing underwriting services on Ethos Technologies Inc.'s behalf. I also authorize Ethos Technologies Inc., its carriers, reinsurer(s) or authorized third-party administrator, to make a brief report of My Information to MIB, Inc.
My Information is to be disclosed under this authorization so that Ethos Technologies Inc. (itself or through its agents, employees, insurance carriers, vendors or representatives) may: 1) underwrite my application for coverage, make eligibility, risk rating, and policy issuance determinations; 2) obtain reinsurance; 3) administer claims and determine or fulfill responsibility for coverage and provision of benefits; 4) administer coverage; and 5) conduct other legally permissible activities that relate to any coverage I have or have applied for with Ethos Technologies Inc.
I understand and acknowledge that any agreements I have made to restrict My Information, including protected health information, do not apply to this Authorization and I instruct any physician, health care professional, hospital, clinic, medical facility or other health care provider, or other entity to release and disclose My Information, including my entire medical record, without restriction except as noted above regarding prior HIV related testing.
This authorization will be valid for two (2) years or a lesser time limit as required by applicable law in the jurisdiction in which any policy is issued.
I understand that I have the right to refuse to sign or to revoke this authorization in writing, at any time, by sending a written request for revocation to the Company at the address listed on www.ethoslife.com. I understand that a revocation is not effective if any of My Providers have relied on this authorization or to the extent that the Company has taken action in reliance on this Authorization or has a legal right to contest a claim under an insurance policy or to contest the policy itself. I understand that any information that is disclosed pursuant to this authorization may be redisclosed and no longer covered by certain federal rules governing privacy and confidentiality of health information.
I understand that if I refuse to sign, alter, or revoke this Authorization the Company may not be able to process my application and it may be a basis for denying my request for coverage, or if coverage has been issued may not be able to make any benefit payments. I understand and acknowledge that I will receive or have received a copy of this authorization.
I understand that My Providers may not refuse to provide treatment or payment for health care services if I refuse to sign this authorization.