Northgate Internal Medicine
Privacy & Health Information Office
1175 Commonwealth Drive, Columbus, OH 43215 · (614) 555-0190 · [email protected]
HIPAA Authorization
Auth. No. HIPAA-26-00831
Issued May 2, 2026

Authorization to Use or Disclose Protected Health Information

Compliant with the Health Insurance Portability and Accountability Act · 45 CFR §164.508
Confidential — Patient Authorized
1
Patient (Individual Authorizing Disclosure)
Full legal name
Priya R. Raman
Date of birth
03 / 22 / 1985
Member / account #
NIM-44-20917
Mailing address
624 Maplewood Court, Worthington, OH 43085
Phone
(614) 555-0241
2
Disclosing Provider & Authorized RecipientI authorize the provider on the left to release my information to the recipient on the right.
AReleases from — my provider
Provider / practice
Northgate Internal Medicine
Address
1175 Commonwealth Drive, Columbus, OH 43215
Phone / fax
(614) 555-0190 / fax (614) 555-0191
BDisclosed to — recipient
Recipient / organization
Meridian Life Insurance Co. — Underwriting Dept.
Address
PO Box 4820, Hartford, CT 06141
Phone / fax
(800) 555-0466 / fax (860) 555-0470
3
Information Authorized for Release
For this underwriting review, I authorize disclosure of the relevant records only checked below — not my complete chart or office visit narratives.
Laboratory resultsBlood panels, urinalysis, screenings
Vital signsBlood pressure, height, weight, BMI
Diagnoses & problem listActive and resolved conditions
Medication listCurrent prescriptions and dosages
Office visit / progress notesExcluded for this purpose
Imaging & radiologyOnly if separately requested
Other (specify):Most recent annual physical summary
Records dated Jan 2021throughpresent or all available dates
4
Purpose & Expiration
Purpose of this disclosure
Insurance underwriting / eligibility Continuing care Personal use Legal
Stated reason
Life insurance underwriting review — application #LF-77104
This authorization expires
6 months from the date signed
on or before November 2, 2026, or upon completion of the underwriting decision, whichever is earlier. If no date is given it expires one year from signing.
5
Your Rights — Please Read Before Signing
  1. Right to revoke. You may revoke this authorization at any time by writing to the Privacy Office above. Revocation stops future disclosures but does not apply to any information already released in reliance on it.
  2. Conditioning. Northgate Internal Medicine will not condition your treatment, payment, or enrollment on whether you sign. However, the recipient named above (an insurer) may lawfully condition coverage or eligibility on receiving this information.
  3. Re-disclosure. Once disclosed to the recipient, your information may no longer be protected by HIPAA and could be re-disclosed by the recipient.
  4. Copies. You are entitled to a copy of this signed authorization, and a photocopy or electronic copy is as valid as the original.
I have read and understand this authorization. I am signing it voluntarily and authorize the disclosure of the information I have marked, to the recipient named, for the purpose stated.
6
Signature
Priya R. Raman
Signature of patient
May 2, 2026
Date signed
Priya Radhika Raman
Printed name
03 / 22 / 1985
Date of birth
Complete only if signed by a personal representative on the patient's behalf (legal guardian, power of attorney, or executor).
Signature of personal representative
Relationship / legal authority
Date
Northgate Internal Medicine · Privacy & Health Information Office HIPAA Authorization · Auth. No. HIPAA-26-00831 · Page 1 of 1