Authorization for Release of PHI Form
If you want the Plan to disclose your protected health information to another individual(s), persons, class of persons,
or organization of your choice (for example, your spouse), you must fill out this form and return it to the Fund Office.
If your spouse and/or Dependent child(ren) over the age of 17 (i.e. Dependent child(ren) who are at least 18 years old)
want the Plan to disclose their protected health information to you, they also must fill out this form and return it to
the Fund office.