This form authorizes MetLife to obtain copies of your medical records. *Please note that if your physician's office or treatment facility requires a separate authorization form, please submit both forms with this packet*

Who can sign the Medical Authorization form?

For this form to be valid it must be signed by the Insured, Spouse, or a primary legal medical representative.

Who is a Legal Medical Representative?

A Legal Medical Representative includes a Medical Power of Attorney (POA), Health Care Proxy/Advanced Health Care Directive, Court-Appointed Guardian, or a HIPAA form from the state. Or the Executor of Estate.

This form authorizes MetLife to release personal health information and policy details about your Long-Term Care claim to another person(s).

Who signs the Privacy Authorization form?

For this form to be valid it must be signed by the Insured, Spouse, or a primary legal financial representative. A copy of the Financial legal document must be included. 

Who is a Legal Financial Representative?

A Legal Financial Representative includes a Durable or Financial Power of Attorney, Court-Appointed Guardian, or a Living Trust. 

Do I need to add Medical Providers on this form? 

The insured does not need to list LTC providers or physicians on this form, we do not use this form to obtain medical records.

Both areas Section 6a/6b need to be completed by the Insured, Spouse, or the Legal Financial Representative.

Who is a Legal Financial Representative?

A Legal Financial Representative includes a Durable or Financial Power of Attorney, Court-Appointed Guardian, or a Living Trust. If the legal documents are not submitted, it may cause delays.  Please note if the Insured is deceased, the Executor of the Estate should sign the Initial Claim Packet and we will need a copy of the Last Will and Testament and/or Executor paperwork

Once all necessary documentation is received, your claim will be assigned to a Care Coordinator for the eligibility review.