Common use of Signature Date Clause in Contracts

Signature Date. Designation of Authorized Representative I, the above signed employee do, hereby appoint (please print) (hereinafter “my Authorized Representative” :) to act on my behalf in pursuing a benefit claim specifically pertaining to my Health FSA/ DCAP account(s). My Authorized Representative shall have full authority to act, on my behalf with respect to an initial determination of a Claim, any requests for documents relating to the Claim and any appeal of an adverse determination of a Claim. I am aware that the Standards for Privacy of Individually Identifiable Health Information set forth by the U.S. Department of Health and Human Services (the “Privacy Standards”), govern access to medical information. I understand that in connection with the performance of his/her duties hereunder, my Authorized Representative may receive my Protected Health Information, as defined in the Privacy Standards, relating to the Claim I hereby consent to any disclosure of my Protected Health Information to my Authorized Representative.