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I am on LTD and have been sent a form to update information as well as this consent form below. Do I have to allow them such blind freedom on who they can speak with about me. AUTHORIZATION FOR RELEASE OF INFORMATION
Contract No.:
I hereby authorize any physician, any other professional and participating party in the hea
care and rehabilitation sectors as well any public or private health or social servic
institution, any insurance company, as well as any insurer, any public or private instituti
any information officer, any market intermediary, any employer or ex-employer,
policyholder as well as any other person who has files or personal information, especi
medical information to provide SQ, Life Insurance Company Inc. (hereinafter SSQ) o
its subsidiaries, affiliates, third party administrators and reinsurers, all information that
she or it has, for the following purposes: to investigate and confirm the accuracy of
claim, determine my eligibility for benefits, administer my claim, assess and facilitate
ability to return to work and administer the group benefits plan and coverage.
I also authorize SQ to disclose this information to the persons indicated above whene
necessary, within the framework of their activities and the processing of my file.
I also authorize SQ and my group policyholder's medical consultants to collect, use
disclose between them information about me including details relating to diagno:
treatment, or medication, that is relevant to my claim, for the purpose of planning
managing my rehabilitation and return to work.
In the event of death, I formally authorize the policyholder, employer, beneficia
successors or assigns, to provide to SQ or to its subsidiaries, affiliates, third pa
administrators and reinsurers, when required, all information or authorizations that ma
possible the processing of my file.
This authorization is valid for the purpose of this contract, its amendment, extension
A photocopy or electronic copy of this authorization shall be as valid as the original.

This authorization is quite broad and you can certainly refuse to provide it, but doing so could trigger the insurer cutting you off. We would of course assist in that case if you were cut off. The alternative is to express to the insurer in writing (via email) your concerns about the broad nature of this authorization, and state to the insurer that you're willing to provide the information they require from your treating physicians but their requests must be specific. Ultimately it’s your choice to sign this authorization, but you're within your rights to so no to such a broad request. Although, again, if you say no, you will need to provide the insurer with an alternative for access to specific information and to understand that the insurer won’t like it and may cut you off as a result.
Sivan Tumarkin
Direct Tel (Toll Free): 1-888-990-9646     Email:     Web:
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