MEMBER AUTHORIZATION FORM

MI-0827-0109
STATE OF NEW JERSEY - DEPARTMENT OF THE TREASURY
DIVISION OF PENSIONS AND BENEFITS
MEMBER AUTHORIZATION FORM
FOR USE AND DISCLOSURE OF PROTECTED AND PRIVATE INFORMATION
Member’s Name: __________________________________________________________________________
LAST
FIRST
MI
Address: ________________________________________________________________________________
________________________________________________________________________________
Daytime Telephone Number: ( ______ ) ________________ E-mail: ________________________________
AREA CODE
Member’s Social Security Number: ________________________________ Date of Birth: ____/____/_____
MM / DD / YYYY
By providing the information below and signing this form, I authorize the Division of Pensions and Benefits to
release and/or disclose my protected and private information. Further, I understand that health information from
the Division can be provided to me but is otherwise “protected health information” pursuant to the Privacy Rule
of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act
(HIPAA) of 1996.
I submit this form voluntarily to document my wishes regarding the use and/or disclosure of the information described below.
1. Description of information I authorize to be used or disclosed. The following is a specific description
of the information I authorize be used and/or disclosed:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
2. I authorize my protected and private information to be used and/or disclosed for the following specific
purposes:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Continued on next page
MI-0827-0109
3. I authorize the following person(s) or organizations to receive my information from the Division of
Pensions and Benefits and to use or disclose such information for the purposes listed above. I understand that
some or all of the information may no longer be protected by federal privacy standards.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
4. Expiration of Authorization. Upon release of the information described above, this authorization request
will expire. Any future requests to release and/or disclose protected and private information will require a
new Member Authorization Form.
MEMBER’S SIGNATURE
I have had an opportunity to review and understand the contents of this form. I have signed this form
voluntarily and confirm that it accurately reflects my wishes regarding the use and/or disclosure of this
information.
_________________________________________________________________ Date: _____/_____/_______
MEMBER’S SIGNATURE
MM /
DD
/
YYYY
If signed by a personal representative, complete the following:
Name of Personal Representative: ____________________________________________________________________
Relationship to Member or Nature of Authority: ___________________________________________________________
(e.g., health care power of attorney, guardian, other legal authorization — A copy of documentation must be attached.):
Address: ________________________________________________________________________________
________________________________________________________________________________
Daytime Telephone Number: ( _______ ) ________________ E-mail: _______________________________________
AREA CODE
_______________________________________________________________________ Date: ______/______/_______
SIGNATURE OF PERSONAL REPRESENTATIVE
Return to:
Office of Client Services
New Jersey Division of Pensions and Benefits
PO Box 295
Trenton, NJ 08625-0295
MM
/
DD
/
YYYY