HIPAA authorization, English

I REQUEST AND AUTHORIZE PRIORITY HEALTH (Priority Health Managed Benefits, Inc.; Priority Health Insurance Company; Priority Health Government Programs, Inc.) TO ALLOW THE PERSON NAMED BELOW TO SEE ALL MY PERSONAL, HEALTH AND CLAIMS INFORMATION.

I understand this includes:

* Claims and billing information for my health care and my prescriptions

* Medical information that Priority Health receives from medical practitioners, including records regarding general medical care, alcohol and drug abuse treatment, psychological or psychiatric treatment, social services counseling, human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC), communicable diseases or infections, venereal diseases, tuberculosis, hepatitis

* Information I have entered in online tools through this website

* Demographic information (age, address, etc.)

I UNDERSTAND THAT THE PERSON TO WHOM MY INFORMATION IS SHOWN MAY POSSIBLY SHOW IT TO OTHERS without my knowledge and consent, and in that case the privacy of my personal and health information may no longer be protected by law.

I understand that I may revoke this Authorization at any time when logged in to my online Priority Health account.

I understand that this Authorization will automatically end one year from the day I sign it.