ACORD 650 Instructions


Section Name Field Name Field and/or Section Description
TITLE ACORD 650 (2009/06) Authorization for the Release of Health Information The title of the form. ACORD 650, Authorization for the Release of Health Information, is used to comply with the HIPAA (Health Insurance Portability and Accountability Act) Privacy Rule. This form authorizes the use and/or disclosure of health information about the applicant by or to specific persons or organizations referenced in this form. This authorization will expire 24 months from the date signed by the applicant or a personal representative of the applicant. This form cannot be used in AZ, IN, MD, ME, MN, NC, NY, VA and VT. Use ACORD 757, HIV Antibody / Antigen Consent and Testing Form, or if applicable, the state specific ACORD 757, if disclosure information about HIV / AIDS status is required.
IDENTIFICATION SECTION Insurer Enter text: The insurer’s full legal company name(s) as found in thefile copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer’s group name or trade name. As used here, the name of Insurance Company must be inserted before this form is used. Use the actual name of the company. Do not use group names.
APPLICANT’S ACKNOWLEDGEMENT Applicant’s Printed Name Enter text: The named insured(s) as it/they will appear on the policy declarations page. As used here, type or print the full name of the applicant as it will appear on the policy declarations page.
APPLICANT’S ACKNOWLEDGEMENT Date of Birth Enter date: The date of birth of the insured. As used here, the date of birth of the applicant. (mm/dd/yyyy).
APPLICANT’S ACKNOWLEDGEMENT Applicant’s Signature Sign here: Accommodates the signature of the applicant or named insured. As used here, the applicant must sign the form.
APPLICANT’S ACKNOWLEDGEMENT Date of Signature Enter date: The date the form was signed by the named insured. As used here, the date the applicant signed the form (mm/dd/yyyy).
APPLICANT’S ACKNOWLEDGEMENT Personal Representative of Applicant Enter text: The description of the representative’s authority to act on behalf of the applicant. As used here, if this authorization is signed by a personal representative of the applicant, provide this description.
Edition Date The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).