VERMEDAUTH (05/06) eF
Metropolitan Life Insurance Company
P.O. Box 14590
Lexington, KY 40511-4590
HIPAA: This Authorization has been carefully and specifi cally drafted to permit disclosure of health information
consistent with the privacy rules adopted subsequently amended by the United States Department of Health and
Human Services pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPPA).
Instructions for completing the form:
1. Complete all applicable areas of the form.
If you are the Authorized Representative, include a copy of the legal document(s) authorizing you to act on the
3. Sign this form.
4. Fax or return form as soon as possible to expedite processing of your claim – retain original for your records.
Your refusal to complete and sign this form may affect your eligibility for benefits under your employer’s disability plan.
Name of Employee (Please Print)
Social Security Number
Claim Number: __________________________________________
Authorization to Disclose Information About Me
For purposes of administering my claim for disability benefi ts under my employer’s short term and long term disability
benefi t plans (which may include assisting me in returning to work), I permit the following disclosures of information:
I permit: any, physician or other medical/treating practitioner, hospital, clinic, other medical related facility or service, or
government agencies administering state funded disability benefi ts or social security, to disclose to Metropolitan Life
Insurance Company (“MetLife”), my employer in its capacity as administrator of my employer’s disability benefi t plans,
and medical consultants and examiners that may be retained in connection with my disability claim any and all informa-
tion concerning my current illness/injury, related medical care, and disability claim. I permit MetLife a