docVERIFY

Authorization for Release of Health Information

By proceeding, you authorize docVERIFY, on behalf of your employer's group health plan, to collect, review, and retain dependent eligibility documentation solely for the purpose of verifying benefit enrollment eligibility. All information submitted is protected under the Health Insurance Portability and Accountability Act (HIPAA) and will be used only for eligibility determination. Documentation will not be shared with unauthorized third parties. You have the right to revoke this authorization in writing at any time by contacting your HR department, though revocation may affect your dependent's benefit enrollment status.