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     Privacy Authorization Forms

     Subscriber's Authorization for Spouse Request Form

     This Authorization Form is used only to give unrestricted authorization to disclose the      covered employee's (subscriber's) Protected Health Information to his or her
     spouse only. Please print this form, complete it, sign it, and provide it to your
     employer. Your employer will submit it to ACS.

     Note: For limited Authorization and any other type of authorization, use the Member's                     Authorization Request Form.


     Member's Authorization Request Form

     This Authorization Form is used to authorize disclosure of any covered person's      Protected Health Information to anyone he or she designates and for any purpose.      Please print this form, complete it, sign it, and provide it to your employer. Your      employer will submit it to ACS.
© Copyright 2008, ACS Benefit Services, Inc. Third Party Administrator. Page last modified: October 1, 2008.
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