I hereby authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, pharmacy benefit manager, medical facility, insurance company, insurance support organization (such as Medical Information Bureau, Inc.) or other health care provider that has provided payment, treatment or services to me or on my behalf (“My Providers”) to disclose my entire medical record and any other protected health information concerning me to Senior Life Insurance Company (the “Company”) and its agents, employees, and representatives. This includes information on the diagnosis or treatment of HIV (Human Immunodeficiency Virus), AIDS (Acquired Immune Deficiency Syndrome), sexually transmitted diseases, information on the diagnosis and treatment of mental illness and the use of alcohol, drugs and tobacco, but excludes psychotherapy notes.

I acknowledge that any agreements I have made to restrict my protected health information do not apply to this Authorization and I instruct My Providers to release and disclose the entire medical records without restrictions

This protected health information is to be disclosed under this Authorization so that the Company may:

1. underwrite my application for coverage, make eligibility, risk rating, policy issuance and enrollment determinations;
2. obtain reinsurance;
3. administer claims and determine or fulfill responsibility for coverage and provision of benefits;
4. administer coverage;
5. conduct other legally permissible activities that relate to any coverage I have or have applied for with the Company.

I understand that this Authorization shall remain in force for 24 months following the date of my signature below, and a copy of this Authorization is as valid as the original. I understand that I have the right to revoke this Authorization in writing, at any time, by sending a written request for revocation to the Company, Attention: HIPAA Privacy Official to the address listed above. I understand that a revocation is not effective to the extent that any of My Providers has relied on this Authorization or to the extent that this Authorization was provided as a condition of obtaining insurance coverage and other law provides the Company with the right to contest a claim for coverage under the policy or the policy itself. I understand that any information disclosed pursuant to this Authorization may be subject to redisclosure by the recipient and may no longer be protected by federal regulations governing privacy and confidentiality of health information. However, the Company will protect the privacy of health information in accordance with other applicable state and/or federal privacy laws and its own privacy policy.

I understand that My Providers may not refuse to provide treatment or payment for health care services if I refuse to sign this Authorization. I further understand that if I refuse to sign this Authorization to release my complete medical records, the Company may not be able to process my application, or if coverage has been issued, may not be able to process policy claims and/or make any benefit payments. I am entitled to receive a copy of this Authorization. My Personal Representative is also entitled to receive a copy of this Authorization.