Disability Insurance Authorization of Information Form
Personal Information
Full Name
Date of Birth
Address
Phone Number
Policy Number
Authorization
Authorized Provider or Organization
Information to be Disclosed
Purpose of Disclosure
Duration of Authorization
Consent & Acknowledgement
I authorize the release of my information as specified above for the purpose of processing my disability insurance claim.
I acknowledge that I may revoke this authorization at any time by providing written notice.
Signature
Date