the archdiocese of new york benefits administration resource guide

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1. I understand that this authorization will expire (select a. or b.): a. on __ __/__ __/__ __ __ __ (DD/MM/YYYY) Initials: _________ b. at the occurrence of the following event: __________________________________Initials: _________ 2. I understand that I may revoke this authorization at any time by notifying the plan in writing, but if I do it won't have any affect on any actions taken before my revocation was received. Initials: ________ ______________________________________________________ Signature of individual or individual’s representative (Form MUST be completed before signing) ____________________________ Date Printed name of individual's representative(if applicable):____________________________________________ Description of representative’s authority to act for the individual: _____________________________________ *YOU MAY REFUSE TO SIGN THIS AUTHORIZATION* NY01/LASKA/855065.1
AUTHORIZATION FOR THE USE AND DISCLOSURE OF INFORMATION This authorization must be dated and signed by the individual or by a person authorized by law to give this authorization. File copy and facsimile transmission are considered equivalent to the original (unless applicable state law provides otherwise). If UnitedHealthcare seeks the authorization from an individual for a use or disclosure of Protected Health Information (PHI), UnitedHealthcare must provide the individual with a copy of the signed authorization. I authorize United HealthCare Insurance Company, and its subsidiaries/affiliates (“UnitedHealthcare”), to use or disclose my medical, claim, or benefit records, including any individually identifiable health information contained in these records, as described below. I understand these records may contain information created by other persons or entities, including physicians and other health care providers as well as information regarding the use of drug and alcohol treatment services, HIV/AIDS treatment, mental health services [Note: Psychotherapy notes may be used/disclosed only pursuant to a separate authorization pertaining only to psychotherapy notes], reproductive health services, and treatment for sexually transmitted diseases. 1. Persons/entities authorized to receive the information (including address of where information should be sent, if applicable): Name: Address: _____________________________________________________________________________________ _____________________________________________________________________________________ 2. Type of information UnitedHealthcare is authorized to use or disclose: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 3. The information will be used or disclosed for the following purposes: At the request of the Individual 4. I understand that I may revoke this authorization at any time by notifying UnitedHealthcare in writing at PO Box 740800, Atlanta, GA, 30374-0800, except to the extent that: (a) UnitedHealthcare has taken action in reliance on this authorization; or (b) If authorization was obtained as a condition for obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy. 5. This authorization expires [on] [upon] ________________[date] or is valid ______________ [event]. Please note: This authorization may be valid for a maximum time period of one year. I understand that once health information about me has been disclosed by United HealthCare Insurance Company to a third party, the health information may no longer be protected by federal privacy laws. ___________________________________________________________________________________________________________ Printed name of individual or individual's representative ___________________________________________________________________________________________________________ If representative, relationship to individual and authority to act for individual _____________________________________________________ _______________________ ______________________ Signature of individual Subscriber Id # Date Form: AUTH MEM 011504 - 10 -
Page 1 and 2: THE ARCHDIOCESE OF NEW YORK BENEFIT
Page 3 and 4: THE ARCHDIOCESE OF NEW YORK BENEFIT
Page 5 and 6: Section I Important Information
Page 7 and 8: NEW EMPLOYEE CHECKLIST The followin
Page 9 and 10: BENEFITS ADMINISTRATOR RESOURCE CON
Page 11 and 12: VENDOR CONTACT PHONE WEBSITES POLIC
Page 13 and 14: RULES FOR MEMBER GROUPS PARTICIPATI
Page 15 and 16: 5. All clergy and religious orders
Page 17 and 18: BENEFIT ELIGIBILITY OUTLINE -5-
Page 19 and 20: BENEFITS ELIGIBILITY EFFECTIVE DATE
Page 21 and 22: DIVISION CLAIM CODES -6-
Page 23: Group 3000 - New York State Continu
Page 27 and 28: HEALTH INSURANCE PORTABILITY & ACCO
Page 29 and 30: Revised: January 1, 2006 Effective:
Page 35: ARCHDIOCESE OF NEW YORK AUTHORIZATI
Page 39 and 40: HOW TO ENROLL IN THE GROUP HEALTH B
Page 41 and 42: Annual Salary (Benefit Administrato
Page 43 and 44: ARCHDIOCESE OF NEW YORK Group Healt
Page 45 and 46: ARCHDIOCESE OF NEW YORK Group Healt
Page 47 and 48: STATEMENT OF DEPENDENT ELIGIBILITY
Page 49 and 50: THE ARCHDIOCESE OF NEW YORK SUMMARY
Page 51 and 52: Choice Plus Benefits Summary Types
Page 53 and 54: UnitedHealthcare Additional Benefit
Page 57 and 58: Choice Plus Benefits Summary Types
Page 59 and 60: UnitedHealthcare Additional Benefit
Page 63 and 64: Medicare Supplemental Plan Benefits
Page 65 and 66: Exclusions UnitedHealthcare Except
Page 67: HOW TO FILE A MEDICAL CLAIM There a
Page 70 and 71: HOW TO FILE A CLAIM FOR PRESCRIPTIO
Page 72 and 73: FILL IN FOR UP TO TWO PEOPLE WHO WI
Page 74 and 75: STEP 2 Submission Requirements: You
Page 77 and 78: ARCHDIOCESE OF NEW YORK BENEFITS TR
Page 79 and 80: ★ ★ REEMPLOYMENT RIGHTS YOUR RI
Page 81 and 82: ARCHDIOCESE OF NEW YORK NOTICE OF G
Page 83 and 84: Archdiocese of New York Group Healt
Page 87 and 88:
GROUP HEALTH BENEFITS FOR EMPLOYEES
Page 89 and 90:
ARCHDIOCESE OF NEW YORK Group Healt
Page 91 and 92:
ARCHDIOCESE OF NEW YORK Group Healt
Page 93 and 94:
___________________________________
Page 95 and 96:
Section VI Administration of Life,
Page 97 and 98:
ARCHDIOCESE OF NEW YORK Life and Ac
Page 99:
HOW TO FILE A CLAIM FOR BASIC GROUP
Page 115 and 116:
GROUP LIFE INSURANCE BENEFITS FOR E
Page 122 and 123:
GROUP LIFE INSURANCE BENEFITS FOR E
Page 128 and 129:
Section VII Administration of Short
Page 130 and 131:
HOW TO FILE A CLAIM FOR NEW YORK ST
Page 132 and 133:
NOTICE AND PROOF OF CLAIM FOR DISAB
Page 134 and 135:
NOTICE AND PROOF OF CLAIM FOR DISAB
Page 136 and 137:
ARCHDIOCESE OF NEW YORK Benefit Pla
Page 148 and 149:
Section IX Administration of Dental
Page 150:
CIGNA Dental for Religious and Cler
Page 153 and 154:
ARCHDIOCESE OF NEW YORK CIGNA Denta
Page 155:
HOW TO FILE A DENTAL CLAIM There ar
Page 160 and 161:
DAVIS VISION CARE VISION CARE BENEF
Page 162 and 163:
ARCHDIOCESE OF NEW YORK Benefit Hig
Page 164 and 165:
HOW TO FILE A VISION CARE CLAIM (Cl
Page 166 and 167:
Section XI Administration of Volunt
Page 168 and 169:
ARCHDIOCESE OF NEW YORK SUPPLEMENTA
Page 170 and 171:
INTERNAL USE ONLY Institution Name:
Page 172 and 173:
PERSONAL HEALTH APPLICATION Thank y
Page 174 and 175:
Employee: First Name_______________
Page 176 and 177:
Employee: First Name_______________
Page 178:
IMPORTANT NOTICE The Archdiocese of
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