Get Hipaa Compliant Authorization

The HIPAA Compliant Authorization is a crucial document that permits GEICO to access your medical records related to your injury. Completing this form accurately is necessary to initiate the review of your claim.

Follow the steps to complete your authorization form online.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Fill in your claim number in the designated space at the top of the form.
3. Next, enter the date you are filling out the form in the specified field.
4. List all healthcare providers who have treated you for your injuries. Include their names and addresses.
5. Provide your full name in the 'Patient' section, ensuring it is printed clearly.
6. Enter your date of birth under the 'DOB' section in the format provided.
7. Write your Social Security number in the designated space, ensuring it is accurate.
8. Indicate the date of the automobile accident or loss in the provided field, ensuring it is correct.
9. Read the authorization statement carefully and make sure you understand what information is being requested.
10. Sign and date the form in the appropriate sections to validate your authorization.
11. If a personal representative is signing on your behalf, ensure they fill out their section, including their signature and date.
12. After filling out the form, save your changes and proceed to download, print, or share the form as needed.

Complete your HIPAA Compliant Authorization online today.