DEAR POLICYHOLDER:
 
IN ACCORDANCE TO THE FEDERAL PRIVACY COMPONENT OF THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA), WHICH BECAME EFFECTIVE AS OF APRIL 14, 2003, YOU MUST FULLY COMPLETE THE NATIONAL FAMILY LIFE INSURANCE CLAIM FORM AND/OR THE ENCLOSED RELEASE FOR MEDICAL INFORMATION FORM. DUE TO THE NEW FEDERAL GUIDELINES, WE WILL NOT BE ALE TO REQUEST ANY PROTECTED HEALTH INFORMATION (PHI) WITHOUT THIS COMPLETED AND SIGNED FORM(S). IT CAN TAKE APPROXIMATELY 8/12 WEEKS FOR OUR OFFICE TO OBTAIN THE MEDICAL RECORDS FOR YOU.

YOU CAN EXPEDITE THE PROCESSING OF YOUR CLAIM BY REQUESTING THE NEEDED MEDICAL INFORMATION YOURSELF. ANY INCOMPLETE INFORMATION ON THE ENCLOSED FORMS WILL ONLY DELAY THE PROCESSING OF YOUR CLAIM.

PLEASE RETURN THE NECESSARY FORMS AS OUTLINED FOR THE TYPE OF CLAIM YOU ARE FILING AS NOTED ON THE ENCLOSED FORM. SHOULD YOU REQUIRE ADDITIONAL ASSISTANCE, PLEASE DO NOT HESITATE TO CONTACT OUR CLAIMS DEPARTMENT.
 
SINCERELY,

CLAIMS DEPARTMENT
 

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NATIONAL FAMILY LIFE INSURANCE CLAIM FORM AND/OR THE ENCLOSED RELEASE FOR MEDICAL INFORMATION FORM