Form HBEX404 Authorization for Release of Personal Information by Authorized Representative - California

Form HBEX404 Authorization for Release of Personal Information by Authorized Representative - California

What Is Form HBEX404?

This is a legal form that was released by the Covered California - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is Form HBEX404?
A: Form HBEX404 is the Authorization for Release of Personal Information by an Authorized Representative in California.

Q: What is the purpose of Form HBEX404?
A: The purpose of Form HBEX404 is to authorize a representative to access and release personal information on behalf of an individual.

Q: Who can use Form HBEX404?
A: Form HBEX404 can be used by individuals in California who want to authorize someone else to access and release their personal information.

Q: What information is required on Form HBEX404?
A: Form HBEX404 requires the individual's name, contact information, and the name and contact information of the authorized representative.

Q: Is there a fee associated with submitting Form HBEX404?
A: No, there is no fee associated with submitting Form HBEX404.

Q: How long is Form HBEX404 valid?
A: Form HBEX404 is valid for one year from the date it is signed, unless otherwise specified.

Q: Can I revoke the authorization granted through Form HBEX404?
A: Yes, you can revoke the authorization granted through Form HBEX404 at any time by submitting a written revocation to the authorized representative and the California Health Benefit Exchange.

Q: What should I do if I have questions or need assistance with Form HBEX404?
A: If you have questions or need assistance with Form HBEX404, you can contact the California Health Benefit Exchange or seek guidance from a legal professional.

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Form Details:

  • Released on August 1, 2015;
  • The latest edition provided by the Covered California;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form HBEX404 by clicking the link below or browse more documents and templates provided by the Covered California.

Download Form HBEX404 Authorization for Release of Personal Information by Authorized Representative - California

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