No insurance institution, agent, or insurance support organization shall use as its disclosure authorization form in connection with insurance transactions a form or statement that authorizes the disclosure of personal or privileged information about an individual to the insurance institution, agent, or insurance support organization, unless the form or statement:
(A) Is written in plain language;
(B) Is dated;
(C) Specifies the types of persons authorized to disclose information about the individual;
(D) Specifies the nature of the information authorized to be disclosed;
(E) Names the insurance institution or agent and identifies by generic reference representatives of the insurance institution to whom the individual is authorizing information to be disclosed;
(F) Specifies the purposes for which the information is collected;
(G) Specifies the length of time such authorization shall remain valid, which shall be no longer than:
(1) In the case of authorizations signed for the purpose of collecting information in connection with an application for an insurance policy, a policy reinstatement, or a request for change in policy benefits, thirty months from the date the authorization is signed;
(2) In the case of authorizations signed for the purpose of collecting information in connection with a claim for benefits under an insurance policy:
(a) The term of coverage of the policy if the claim is for a health insurance benefit;
(b) The duration of the claim if the claim is not for a health insurance benefit.
(H) Advises the individual or a person authorized to act on behalf of the individual that the individual or the individual's authorized representative is entitled to receive a copy of the authorization form.
Effective Date: 06-29-1995