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OneDigital Benemax, Inc., PO Box 950, Seven West Mill Street, Medfield, Massachusetts, 02052 508-359-4107 | www.Benemax.com AUTHORIZATION FOR THE USE AND DISCLOSURE OF INFORMATION I authorize OneDigital Benemax Inc. to disclose the medical, claim or benefit records identified below, including any individually identifiable health information contained in these records to ___________________ located at the following address _____________________________ and who can be contacted via telephone at _____________. OneDigital Benemax Inc. may provide copies of my explanation of benefits, provider billing documents including my provider’s name, specialties, addresses, tax ID numbers, and any other information that is requested by _________________ concerning the items identified below. I understand these records may contain information created by other persons or entities, including health care providers as well as information regarding the use of drug and alcohol treatment services, HIV/AIDS treatment, mental health services, reproductive health services, and treatment for sexually transmitted diseases. (Please check one) ______ All information relating to the provision of and payment for my medical, dental, FSA and/or COBRA benefits or services. ______ All information relating to the following claim (list date of service, provider, diagnosis, procedure and other relevant information). __________________________________________________________________________________________________________________________________________________________________________ I understand that this authorization is voluntary and is not a condition of enrollment in my plan, eligibility for benefits or payment of claims. I understand that I may revoke this authorization at any time by notifying OneDigital Benemax Inc. This authorization will automatically expire one year from the date signed or upon my termination of benefits. Furthermore, I understand the Garnett and Cowles will keep this information protected under federal privacy laws and only use it to the extent allowed in this document. Printed name of member or member’s dependent If member’s dependent list relationship ___________________________________________ __________________________________ Signature of individual member or guardian Date Signed If member/dependent is over 18 years of age they must sign for authorization.