Financial Institutions Declaration Form



Fill in name of institution/person (Bank/Investment firm/Financial Planner/Life Insurer/Credit Card Company/Other)

I find the Congressionally-permitted and federally-approved use and disclosure of health information by various financial institutions to be detrimental to medical privacy and the confidentiality of medical records and individually-identifiable health data. Title V of the Financial Modernization Act, (15 U.S.C. 6801 et seq.) popularly referred to as the Gramm-Leach-Bliley Act (GLBA) which was signed into law November 12, 1999, became effective July 1, 2001 and has allowed regulators to issue a long list of exceptions to the requirement of patient and consumer consent.

For the record, I therefore and hereby declare my express wish and intent to prevent medical records and health information from access or disclosure by the above named person/corporation/agency without my express written, informed and voluntary consent. Please keep this form on file. To be specific, without written, specific, informed and voluntary consent, I ask that the medical, psychological, financial, genetic, or other personal data of ________________________________________ (Name of self, child, or guardian responsibility) not be disclosed, used, placed in a database, or otherwise accessed for the following functions/entities as checked below:

 Case management
 Claims administration
 Disease management
 Quality assurance/ improvement
 Reinsurance & excess loss insurance
 Ratemaking & guaranty fund functions
 Actuarial, scientific, medical or public policy research
 Claims adjustment and management
 Database security
 External accreditation standards
 Grievance procedures
 Provider credentialing verification
 Policyholder service functions
 Policy placement or issuance
 Peer review activities
 Risk management
 Loss control
 Utilization review
 Investigation or underwriting
 Performance evaluation
 Third parties and affiliates
 Administration of consumer disputes and inquiries
 Detection, investigation or reporting of actual or potential fraud, misrepresentation or criminal activity
 Internal administration of compliance, managerial, and information systems
 Any activity that permits disclosure without authorization pursuant to the federal Health Insurance Portability and Accountability Act privacy rules promulgated by the U.S. Department of Health and Human Services
 Replacement of a group benefit plan or workers compensation policy or program
 Activities in connection with a sale, merger, transfer or exchange of all or part of a business or operating unit
 Disclosure that is required, or is one of the lawful or appropriate methods, to enforce the licensee's rights or the rights of other persons engaged in carrying out a transaction or providing a product or service that a consumer requests or authorizes
 Any activity otherwise permitted by law, required pursuant to governmental reporting authority, or to comply with legal process
 'Additional insurance functions' that may be added with approval of the commissioner of insurance "to the extent they are necessary for appropriate performance of insurance functions and are fair and reasonable to the interest of consumers."

This restriction on data disclosure, use and access shall be valid until otherwise removed by written authorization of the subject (or parent or guardian of subject if subject is a minor or under guardianship) of the information.


Relationship to Above Person


Printed Full Name


City / State

Zip code

CCHC DISCLAIMER: CCHC is a non-profit 501(c)3 organization. CCHC provides this form only as information to assist individuals in restricting access to or use of their individually-identifiable medical or financial information. CCHC specifically does not warrant the effectiveness of said form in restricting access to or use of personal information by government agencies or private organizations. CCHC is not liable for any injury, either in whole or in part, caused, directly or indirectly, by use of this form. With the advice to the user that under the law this form may not be binding, it does however express your desire for medical, financial and personal privacy. It also expresses your protest if your medical records and other personal information are accessed, used or disclosed without your written, informed and voluntary consent.

Form created and distributed for CCHC's:
"For the Record" Medical Privacy Project
Citizens' Council on Health Care
1954 University Ave. W., Suite 8
St. Paul, MN 55104, 651-646-8935,

Copyright © Citizens' Council on Health Care 2001