Fillable Genworth Life and Health Insurance Company HIPAA Privacy Department P

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Genworth Financial Employee Benefits Group Genworth Life and Health Insurance Company HIPAA Privacy Department P.O. Box 810 Greenfield, MA 01302 AU T H O R I Z AT I O N F O R M E M B E R I N I T I AT E D R E QU E S T F O R R E L E A S E O F P ROT E C T E D H E A LT H I N F O R M AT I O N Name of Employer Primary Member/Employee Covered by the Health Plan (Last, First) Group Account Number (Policy Number) Primary...
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