Eureka College New Student Packet 2013-14 | Page 18

insuranceverification

(This side of the form is required to be completed by all athletes at Eureka College.)
AUTHORIZATION – To Permit Use and Disclosure of Health Information
This Authorization was prepared by First Agency, Inc. and Eureka College for purposes of obtaining information necessary to process a claim for benefits.
Upon presentation of the original or a photocopy of this signed Authorization, I authorize, without restriction (except
psychotherapy notes), any licensed physician, medical professional, hospital or other medical-care institution, insurance
support organization, pharmacy, governmental agency, insurance company, group policyholder, employer or benefit plan
administrator to provide First Agency, Inc., Eureka College or any agent, attorney, consumer reporting agency or independent administrator, acting on its behalf, all information concerning advice, care or treatment provided the patient,
employee or deceased named below, including all information relating to, mental illness, use of drugs or use of alcohol.
This Authorization also includes information provided to our health division for underwriting or claim servicing and
information provided to any affiliated insurance company on previous applications. If this Authorization is for someone
other than myself, that individual has given me authority to act on his/her behalf as explained below.
I understand that I have the right to revoke this Authorization, in writing, at any time by sending written notifi cation to
Eureka College or to First Agency at 5071 West H Avenue, Kalamazoo, MI 49009-8501. I understand tha H