To any medical care provider, medical care facility, insurer, government-sponsored health plan, or employer: I authorize the release of any medical information about me to Arch insurance Company, or it’s authorized representative, Administrative Concepts Inc. This applies to all information about the diagnosis, treatment, or prognosis of any illness or injury I now have or have had in the past.
To any insurance company, any travel organization or agency, airline carrier, cruise line, tour operator, rental agency, hotel, motel, or similar entity providing lodging on a rental / lease basis or any other person who may have knowledge regarding this claim: I authorize the release any information requested regarding this claim and the loss reported.
The company will use this information to determine if any claim is eligible. Any information obtained will not be released by the Company except to my primary health insurance carrier (if any) or persons or organizations performing investigation or legal services for the Company in connection with my claim. A copy of this authorization shall be considered as effect and valid as the original and shall remain in effect for one year from the date of authorization.
I certify that the information given by me in support of my claim is true and correct. I understand that any person who knowingly and with intent to defraud or deceive any insurance company, files a claim containing any materially false, incomplete or misleading information may be subject to prosecution or insurance fraud.