Form Si 3379 Cta PDF Details

The Si 3379 CTA form is an essential document designed by Standard Insurance Company for individuals seeking to apply for disability benefits, particularly those affiliated with CTA Benefits and Services. This comprehensive form is part of a disability benefits claim packet that meticulously guides applicants through the process of filing a claim. Applicants are required to engage with four distinct forms, each playing a pivotal role in the application process. The Employee’s Statement is the cornerstone of the application, demanding thorough responses to all inquiries, including specifics about injuries, illnesses, or pregnancies that lead to disability claims. To prevent delays, every part of these forms must be completed, with instructions advising to mark sections that aren't applicable with "NA" to indicate no oversight. Furthermore, the form emphasizes the necessity of attaching supporting documents such as Social Security or Workers’ Compensation benefit determinations to aid in the accurate calculation of monthly benefits. Additionally, the inclusion of the Authorization to Obtain and Release Information, alongside a separate authorization concerning psychotherapy notes, underlines the form’s comprehensive approach to gathering relevant information. This is further supported by the need for statements from Attending Physicians and Employers, to furnish a multi-faceted view of the claimant’s situation. These documents combined ensure that Standard Insurance Company has a holistic understanding of the claim, thereby facilitating a smoother review process. The detailed structure of the Si 3379 CTA form showcases the rigorous approach adopted by Standard Insurance Company in administering disability benefits, highlighting their commitment to providing clarity and support to applicants throughout the process.

QuestionAnswer
Form NameForm Si 3379 Cta
Form Length17 pages
Fillable?No
Fillable fields0
Avg. time to fill out4 min 15 sec
Other namesnotied, insurer, CALIFORNIA, si3379cta

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Standard Insurance Company – CTA Benefits and Services PO Box 2773 Portland OR 97208

Tel 800.522.0406 Fax 888.414.0390

Disability Benefits Claim Packet Instructions

PLEASE READ CAREFULLY

Your application for benefits consists of four forms. Every space on these forms should be filled in to avoid delay in processing your application. If a section does not apply, or information is not available, “NA” should be written in the space so that we know you did not overlook that particular question. If a form is received incomplete, it may be returned for completion.

The four forms are:

1.The Employee’s Statement

●Answer every question completely. Be sure to use the appropriate section for injury, sickness or pregnancy. If a question does not apply to you write “NA”.

●

●

Use an additional page, if necessary, to give full and complete answers.

Attach copies of any Social Security, Public Employees Retirement System, State Teachers Retirement System, Workers’ Compensation or other benefit determinations you have received. If you have applied for any other benefits but have not yet received them, please send a copy of the application receipt. This information is needed to accurately calculate your monthly benefits. If you are unable to make copies of these documents please send the originals. We will photocopy and return them to you promptly.

●Remember to sign and date your statement. An unsigned or undated statement will be returned to you.

2.The Authorization to Obtain and Release Information

The Authorization to Obtain and Release Psychotherapy Notes

●Please sign and date the Authorization to Obtain and Release Information and attach it to the Employee’s Statement. Your signature lets Standard Insurance Company (The Standard) get the information about you that we need to determine your eligibility for benefits. The Authorization to Obtain and Release Information also lets The Standard release this information to specific persons.

If you have seen or been treated by a Psychiatrist, Psychotherapist, Psychologist, Clinical Social Worker (MSW, MCSW, etc.), or any other provider of treatment for a mental condition, please sign and return the Authorization to Obtain and Release Information and the Authorization to Obtain and Release Psychotherapy Notes.

You will receive copies of these Authorizations upon your request.

3.The Attending Physician’s Statement

●

●

Part A should be completed by you.

Part B should be completed by your physician. If you have seen more than one physician for your disability, a statement should be completed by each physician. Your physician(s) should mail the completed form directly

to The Standard.

4.The Employer’s Statement

● This form should be completed by your employer, who will mail it to The Standard.

You are responsible for making sure all required forms are completed and returned to our office. If you have any questions,

our office is here to help you.

SI 3379 CTA

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CTA Benefits and Services

 

 

 

 

Disability Insurance

PO Box 2773 Portland OR 97208

Tel 800.522.0406 Fax 888.414.0390

Employee’s Statement

Please print clearly. Form may be returned for unanswered questions.

1. CLAIMANT

Last Name:

 

 

 

 

 

 

 

 

First Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Middle Name:

 

 

 

 

 

 

 

 

Suffix:

 

 

 

 

 

 

 

Social Security No.:

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

Zip Code:

 

 

 

Phone No.:

 

 

 

 

 

 

 

 

Patient No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birthdate:

 

 

 

 

 

 

 

 

Gender: Male

Female

Height:

 

 

Weight:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse/Domestic Partner Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name:

 

 

 

 

 

 

 

 

First Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Middle Name:

 

 

 

 

 

 

 

 

Suffix:

 

 

 

 

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No. of dependent children:

 

Birthdate of youngest:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you receive a Certificate of Insurance? Yes No

 

Did you receive a Brochure?

Yes

No

 

If no, please contact The Standard.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. EMPLOYMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

School District Name:

 

 

 

 

 

 

 

 

Group Policy No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

Zip Code:

 

 

 

Phone No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Job title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Describe your Job Duties:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is your disability work-related?

 

Yes

No

Date of injury:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you filed a Workers’ Compensation claim?

Yes

No

If Yes, W.C. claim number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last full day at work:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date you became unable to work at your occupation as a result of disability:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you now or have you worked at your occupation or any other occupation since the date of your injury?

 

Yes

No

 

If yes, provide name of employer and

dates of employment:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone No.:

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

Zip Code:

 

 

 

Employment Start Date:

 

 

 

 

 

 

 

 

Employment End Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you self-employed at any activity?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date you resumed part-time work:

 

 

 

 

 

Work

Phone:

 

 

 

 

 

 

Extension:

 

 

 

 

 

Date you resumed full-time work:

 

 

 

 

Work

Phone:

 

 

 

 

 

 

Extension:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SI 3379 CTA

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%!

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Standard Insurance Company

CTA Benefits and Services

PO Box 2773 Portland OR 97208

Tel 800.522.0406 Fax 888.414.0390

Disability Insurance Employee’s Statement

Claimant’s Name:

3.SICKNESS Please list all illnesses which contribute to your being unable to work at your occupation.

Illness:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date First Noticed:

 

 

Illness:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date First Noticed:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State what you believe caused your illness.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Describe your symptoms:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever had the same condition or a related illness before? Yes

No

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. INJURY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Describe Injuries:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cause of Injuries:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date injury occurred:

 

 

 

Time injury occurred:

 

 

 

 

 

 

Location where injury occurred:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. PREGNANCY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date you expect to cease work:

 

 

 

 

 

Expected delivery date:

 

 

 

 

 

 

Actual delivery date:

 

 

 

 

 

Expected return to work date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please indicate any foreseeable complications.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. ATTENDING PHYSICIAN List all physicians consulted for this injury or illness. Use separate sheet, if needed.

 

 

 

 

 

Physician’s Last Name:

 

 

 

First Name:

 

 

 

 

 

 

Specialty:

 

 

 

 

 

Phone No.:

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

Zip Code:

 

 

Date first consulted for this injury or illness:

 

 

 

 

 

Date last consulted:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician’s Last Name:

 

 

First Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specialty:

 

 

 

Phone No.:

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

Zip Code:

 

 

Date first consulted for this injury or illness:

 

 

 

 

 

Date last consulted:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician’s Last Name:

 

 

 

First Name:

 

 

 

 

 

 

Specialty:

 

 

 

Phone No.:

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

Zip Code:

 

 

Date first consulted for this injury or illness:

 

 

 

 

Date last consulted:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SI 3379 CTA

3 of 17

(8/14)

Standard Insurance Company

CTA Benefits and Services

PO Box 2773 Portland OR 97208

Tel 800.522.0406 Fax 888.414.0390

Disability Insurance Employee’s Statement

Claimant’s Name:

7. HOSPITAL If you were hospitalized for this condition, please complete. Please attach copy of hospital bill if available.

Hospital Name:

Address:

City:

 

 

 

 

 

 

State:

 

Zip Code:

 

From:

 

through:

 

Reason for hospitalization:

 

 

 

 

From:

 

through:

 

Reason for hospitalization:

 

 

 

 

8. HISTORY List all illnesses or injuries for which you have received treatment over the past five years. Use separate sheet if needed.

Ailment:

 

 

Date of treatment:

 

 

 

 

 

 

Physician’s Last Name:

 

First Name:

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

State:

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

Ailment:

 

 

Date of treatment:

 

 

 

 

 

 

Physician’s Last Name:

 

First Name:

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

State:

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

Ailment:

 

 

Date of treatment:

 

 

 

 

 

 

Physician’s Last Name:

 

First Name:

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

State:

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

Ailment:

 

 

Date of treatment:

 

 

 

 

 

 

Physician’s Last Name:

 

First Name:

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

State:

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

Ailment:

 

 

Date of treatment:

 

 

 

 

 

 

Physician’s Last Name:

 

First Name:

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

State:

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

Ailment:

 

 

Date of treatment:

 

 

 

 

 

 

Physician’s Last Name:

 

First Name:

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

State:

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SI 3379 CTA

4 of 17

(8/14)

Standard Insurance Company

CTA Benefits and Services

PO Box 2773 Portland OR 97208

Tel 800.522.0406 Fax 888.414.0390

Disability Insurance Employee’s Statement

Claimant’s Name:

DEDUCTIBLE INCOME/INCOME FROM OTHER SOURCES

Your Group Disability plan is designed so that the income you receive from The Standard and other sources (Social Security, Workers’ Compensation and other benefits as described in your Group Policy) will equal the percentage described in your Group Policy. You should check your Group Policy to determine how other benefits may impact your disability benefits. You must send The Standard copies of all of your benefit determinations and related determinations. The policy under which you are insured may require that The Standard benefit payment be reduced by actual or estimated benefits payable from additional sources.

9. DEDUCTIBLE INCOME

Have you applied for or are you receiving

Applied

Receiving

 

Date Applied

 

Amount Received

Effective

benefits from:

Yes No

Yes No

 

For

 

Weekly

Monthly

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Social Security

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Workers’ Compensation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. State Disability Insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. Retirement or Pension (Employer, PERS, STRS, etc.)

 

 

 

 

 

 

 

 

 

 

 

Please specify type

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. Other

 

 

 

 

 

 

 

 

 

 

 

 

 

(e.g., unemployment or union benefits, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please send copies of any letters or notices approving or denying benefits.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. INCOME FROM OTHER SOURCES

 

 

 

 

 

 

 

 

 

 

 

 

Are you receiving income from:

 

 

Effective Date

 

 

Daily Amount Received

 

 

Limit Date

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Substitute Differential Pay

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Fully Paid Sick Leave

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Acknowledgement

I hereby certify that the answers I have made to the foregoing questions are both complete and true to the best of my knowledge and belief. I acknowledge that I have read the applicable fraud notice on page 6 of this form.

SIGNATURE

DATE

SI 3379 CTA

5 of 17

(8/14)

Standard Insurance Company

CTA Benefits and Services

PO Box 2773 Portland OR 97208

Tel 800.522.0406 Fax 888.414.0390

Disability Insurance Claim Form Fraud Notices

Some states require us to provide the following information to you:

ALABAMA, MARYLAND AND RHODE ISLAND RESIDENTS

Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

CALIFORNIA RESIDENTS

For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

COLORADO RESIDENTS

It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to the policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

DISTRICT OF COLUMBIA RESIDENTS

WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant.

FLORIDA RESIDENTS

Any person who knowingly and with intent to injure, defraud or deceive an insurance company, files a statement of claim or an application containing false, incomplete or misleading information is guilty of a felony of the third degree

NEW JERSEY RESIDENTS

Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

NEW YORK RESIDENTS

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim, containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

PENNSYLVANIA RESIDENTS

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

ALL OTHER RESIDENTS

Some states require us to inform you that any person who knowingly and with intent to injure, defraud or deceive an insurance company, or other person, files a statement containing false or misleading information concerning any fact material hereto commits a fraudulent insurance act which is subject to civil and/or criminal penalties, depending upon the state. Such actions may be deemed a felony and substantial fines may be imposed.

SI 3379 CTA

6 of 17

(8/14)

Standard Insurance Company

CTA Benefits and Services

Return to page 1

PO Box 2773 Portland OR 97208

Tel 800.522.0406 Fax 888.414.0390

Authorization to Obtain and Release Information

I AUTHORIZE THESE PERSONS having any records or knowledge of me or my health:

•Any physician, medical practitioner or health care provider.

•Any hospital, clinic, pharmacy or other medical or medically related facility or association.

•Kaiser Permanente.

•Any insurance company or annuity company.

•Any employer, policyholder or plan sponsor.

•Any organization or entity administering a benefit or leave program (including statutory benefits) or an annuity program.

•Any educational, vocational or rehabilitation counselor, organization or program.

•Any consumer reporting agency, financial institution, accountant, or tax preparer.

•Any government agency (for example, Social Security Administration, Public Retirement System, Railroad Retirement Board, Workers’ Compensation Board, etc.).

TO GIVE THIS INFORMATION:

•Charts, notes, x-rays, operative reports, lab and medication records and all other medical information about me, including medical history, diagnosis, testing and test results. Prognosis and treatment of any physical or mental condition, including:

•Any disorder of the immune system, including HIV, Acquired Immune Deficiency Syndrome (AIDS) or other related syndromes or complexes.

•Any communicable disease or disorder.

•Any psychiatric or psychological condition, including test results, but excluding psychotherapy notes. Psychotherapy notes do not include a summary of diagnosis, functional status, the treatment plan, symptoms, prognosis and progress to date.

•Any condition, treatment, or therapy related to substance abuse, including alcohol and drugs.

and:

•Any non-medical information requested about me, including such things as education, employment history, earnings or finances, return to work accommodation discussions or evaluations, and eligibility for other benefits or leave periods including, but not limited to, claims status, benefit amount, payments, settlement terms, effective and termination dates, plan or program contributions, etc.

TO STANDARD INSURANCE COMPANY, THE STANDARD LIFE INSURANCE COMPANY OF NEW YORK, THE STANDARD BENEFIT ADMINISTRATORS AND THEIR AUTHORIZED REPRESENTATIVES (referred to as “The Companies”, individually and collectively), AND MY EMPLOYER’S ABSENCE MANAGEMENT PROGRAM ADMINISTRATOR (“Absence Manager”).

•I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization and I instruct the persons and organizations identified above to release and disclose my entire medical record without restriction.

•I understand that each of The Companies and Absence Manager will gather my information only if they are administering or deciding my disability or leave of absence claim(s), and will use the information to determine my eligibility or entitlement for benefits or leave of absence.

•I understand that I have the right to refuse to sign this authorization and a right to revoke this authorization at any time by sending a written statement to The Companies and Absence Manager, except to the extent the authorization has been relied upon to disclose requested records. A revocation of the authorization, or the failure to sign the authorization, may impair The Companies and Absence Manager’s ability to evaluate or process my claim(s), and may be a basis for denying or closing my claim(s) for benefits or leave of absence.

•I understand that in the course of conducting its business The Companies and Absence Manager may disclose to other parties information about me. They may release information to a reinsurer, a plan administrator, plan sponsor, or any person performing business or legal services for them in connection with my claim(s). I understand that The Companies and Absence Manager will release information to my employer necessary for absence management, for return to work and accommodation discussions, and when performing administration of my employer’s self-funded (and not insured) disability plans.

•I understand that The Companies and Absence Manager comply with state and federal laws and regulations enacted to protect my privacy. I also understand that the information disclosed to them pursuant to this authorization may be subject to redisclosure with my authorization or as otherwise permitted or required by law. Information retained and disclosed by The Companies and Absence Manager may not be protected under the Health Insurance Portability and Accountability Act [HIPAA].

•I understand and agree that this authorization as used to gather information shall remain in force from the date signed below:

•For Standard Insurance Company, the duration of my claim(s) or 24 months, whichever occurs first.

•For The Standard Life Insurance Company of New York, the duration of my claim(s) or 24 months, whichever occurs first.

•For The Standard Benefit Administrators, the duration of my claim(s) administered by The Standard Benefit Administrators or 24 months, whichever occurs first.

•For Absence Manager, 24 months.

•I understand and agree that The Companies and Absence Manager may share information with each other regarding my disability and leave of absence claim(s). This authorization to share information shall remain valid for 12 months from the date signed below.

•I acknowledge that I have read this authorization and the New Mexico notice on page 8. A photocopy or facsimile of this authorization is as valid as the original and will be provided to me upon request.

Name (please print)

 

 

Social Security No.

 

Signature of Claimant/Representative

 

Date

 

 

If signature is provided by legal representative (e.g., Attorney in Fact, guardian or conservator), please attach documentation of legal status.

SI 3379 CTA

7 of 17

(8/14)

Standard Insurance Company

CTA Benefits and Services

PO Box 2773 Portland OR 97208

Tel 800.522.0406 Fax 888.414.0390

Authorization to Obtain and Release Information

Standard Insurance Company is a licensed insurance company in all states except New York. The Standard Life Insurance Company of New York is an insurance company licensed only in New York. An absence manager may be hired by your employer and may be one of The Companies.

FOR RESIDENTS OF NEW MEXICO

The state of New Mexico requires Standard Insurance Company to provide you with the following information pursuant to its Domestic Abuse Insurance Protection Act.

The Authorization form allows Standard Insurance Company to obtain personal information as it determines your eligibility for insurance benefits. The information obtained from you and from other sources may include confidential abuse information. “Confidential abuse information” means information about acts of domestic abuse or abuse status, the work or home address or telephone number of a victim of domestic abuse or the status of an applicant or insured as a family member, employer or associate of a victim of domestic abuse or a person with whom an applicant or insured is known to have a direct, close personal, family or abuse-related counseling relationship. With respect to confidential abuse information, you may revoke this authorization in writing, effective ten days after receipt by Standard Insurance Company, understanding that doing so may result in a claim being denied or may adversely affect a pending insurance action.

Standard Insurance Company is prohibited by law from using abuse status as a basis for denying, refusing to issue, renew or reissue or canceling or otherwise terminating a policy, restricting or excluding coverage or benefits of a policy or charging a higher premium for a policy.

Upon written request you have the right to review your confidential abuse information obtained by Standard Insurance Company. Within 30 business days of receiving the request, Standard Insurance Company will mail you a copy of the information pertaining to you. After you have reviewed the information, you may request that we correct, amend or delete any confidential abuse information which you believe is incorrect. Standard Insurance Company will carefully review your request and make changes when justified. If you would like more information about this right or our information practices, a full notice can be obtained by writing to us.

If you wish to be a protected person (a victim of domestic abuse who has notified Standard Insurance Company that you are or have been a victim of domestic abuse) and participate in Standard Insurance Company’s location information confidentiality program, your request should be sent to Standard Insurance Company.

SI 3379 CTA

8 of 17

(8/14)

Standard Insurance Company

CTA Benefits and Services

Return to page 1

PO Box 2773 Portland OR 97208

Tel 800.522.0406 Fax 888.414.0390

Authorization to Obtain and Release Psychotherapy Notes

I AUTHORIZE THESE PERSONS having any records or knowledge of me or my health:

•Any physician, medical practitioner or health care provider.

•Any hospital, clinic, pharmacy or other medical or medically related facility or association.

•Kaiser Permanente.

•Any insurance company.

•Any organization or entity administering a benefit or leave program (including statutory benefits)

•Any government agency (for example, Social Security Administration, Public Retirement System, Railroad Retirement Board, Workers’ Compensation Board, etc.).

TO GIVE THIS INFORMATION:

•Notes recorded by a health care provider who is a mental health professional documenting or analyzing the contents of conversation(s) during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of my medical record.

TO STANDARD INSURANCE COMPANY, THE STANDARD LIFE INSURANCE COMPANY OF NEW YORK, THE STANDARD BENEFIT ADMINISTRATORS AND THEIR AUTHORIZED REPRESENTATIVES (referred to as “The Companies”, individually and collectively), AND MY EMPLOYER’S ABSENCE MANAGEMENT PROGRAM ADMINISTRATOR (“Absence Manager”).

•I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization and I instruct the persons and organizations identified above to release and disclose my entire medical record without restriction.

•I understand that each of The Companies and Absence Manager will gather my information only if they are administering or deciding my disability or leave of absence claim(s), and will use the information to determine my eligibility or entitlement for benefits or leave of absence.

•I understand that I have the right to refuse to sign this authorization and a right to revoke this authorization at any time by sending a written statement to The Companies and Absence Manager, except to the extent the authorization has been relied upon to disclose requested records. A revocation of the authorization, or the failure to sign the authorization, may impair The Companies and Absence Manager’s ability to evaluate or process my claim(s), and may be a basis for denying or closing my claim(s) for benefits or leave of absence.

•I understand that in the course of conducting its business The Companies and Absence Manager may disclose to other parties information about me. They may release information to a reinsurer, a plan administrator, plan sponsor, or any person performing business or legal services for them in connection with my claim(s). I understand that The Companies and Absence Manager will release information to my employer necessary for absence management, for return to work and accommodation discussions, and when performing administration of my employer’s self-funded (and not insured) disability plans.

•I understand that The Companies and Absence Manager comply with state and federal laws and regulations enacted to protect my privacy. I also understand that the information disclosed to them pursuant to this authorization may be subject to redisclosure with my authorization or as otherwise permitted or required by law. Information retained and disclosed by The Companies and Absence Manager may not be protected under the Health Insurance Portability and Accountability Act [HIPAA].

•I understand and agree that this authorization as used to gather information shall remain in force from the date signed below:

•For Standard Insurance Company, the duration of my claim(s) or 24 months, whichever occurs first.

•For The Standard Life Insurance Company of New York, the duration of my claim(s) or 24 months, whichever occurs first.

•For The Standard Benefit Administrators, the duration of my claim(s) administered by The Standard Benefit Administrators or 24 months, whichever occurs first.

•For Absence Manager, 24 months.

•I understand and agree that The Companies and Absence Manager may share information with each other regarding my disability and leave of absence claim(s). This authorization to share information shall remain valid for 12 months from the date signed below.

•I acknowledge that I have read this authorization and the New Mexico notice on page 10. A photocopy or facsimile of this authorization is as valid as the original and will be provided to me upon request.

Name (please print)

 

 

Social Security No.

 

Signature of Claimant/Representative

 

Date

 

 

If signature is provided by legal representative (e.g., Attorney in Fact, guardian or conservator), please attach documentation of legal status.

SI 3379 CTA

9 of 17

(8/14)

Standard Insurance Company

CTA Benefits and Services

PO Box 2773 Portland OR 97208

Tel 800.522.0406 Fax 888.414.0390

Authorization to Obtain and Release Psychotherapy Notes

Standard Insurance Company is a licensed insurance company in all states except New York. The Standard Life Insurance Company of New York is an insurance company licensed only in New York. An absence manager may be hired by your employer and may be one of The Companies.

FOR RESIDENTS OF NEW MEXICO

The state of New Mexico requires Standard Insurance Company to provide you with the following information pursuant to its Domestic Abuse Insurance Protection Act.

The Authorization form allows Standard Insurance Company to obtain personal information as it determines your eligibility for insurance benefits. The information obtained from you and from other sources may include confidential abuse information. “Confidential abuse information” means information about acts of domestic abuse or abuse status, the work or home address or telephone number of a victim of domestic abuse or the status of an applicant or insured as a family member, employer or associate of a victim of domestic abuse or a person with whom an applicant or insured is known to have a direct, close personal, family or abuse-related counseling relationship. With respect to confidential abuse information, you may revoke this authorization in writing, effective ten days after receipt by Standard Insurance Company, understanding that doing so may result in a claim being denied or may adversely affect a pending insurance action.

Standard Insurance Company is prohibited by law from using abuse status as a basis for denying, refusing to issue, renew or reissue or canceling or otherwise terminating a policy, restricting or excluding coverage or benefits of a policy or charging a higher premium for a policy.

Upon written request you have the right to review your confidential abuse information obtained by Standard Insurance Company. Within 30 business days of receiving the request, Standard Insurance Company will mail you a copy of the information pertaining to you. After you have reviewed the information, you may request that we correct, amend or delete any confidential abuse information which you believe is incorrect. Standard Insurance Company will carefully review your request and make changes when justified. If you would like more information about this right or our information practices, a full notice can be obtained by writing to us.

If you wish to be a protected person (a victim of domestic abuse who has notified Standard Insurance Company that you are or have been a victim of domestic abuse) and participate in Standard Insurance Company’s location information confidentiality program, your request should be sent to Standard Insurance Company.

SI 3379 CTA

10 of 17

(8/14)

How to Edit Form Si 3379 Cta Online for Free

Our top level developers have worked collectively to get the PDF editor that you'll apply. This particular software makes it simple to submit CTA forms promptly and efficiently. This is certainly all you need to conduct.

Step 1: You can click the orange "Get Form Now" button at the top of this web page.

Step 2: You can see each of the options that it's possible to use on the template as soon as you've accessed the CTA editing page.

Fill out the CTA PDF by typing in the text needed for each individual section.

step 1 to writing STRS

Inside the section Standard Insurance Company CTA, Please print clearly Form may be, Disability Insurance Employees, CLAIMANT, Last Name, Middle Name, Address, City, Phone No, Birthdate, First Name, Suffi x, Patient No, Social Security No, and State write down the data which the system asks you to do.

Standard Insurance Company CTA, Please print clearly Form may be, Disability Insurance Employees, CLAIMANT, Last Name, Middle Name, Address, City, Phone No, Birthdate, First Name, Suffi x, Patient No, Social Security No, and State in STRS

The application will require particulars to quickly prepare the part No of dependent children, Birthdate of youngest, Did you receive a Certifi cate of, Did you receive a Brochure Yes No, If no please contact The Standard, EMPLOYMENT, School District Name, Address, City, Phone No, Job title, Describe your Job Duties, Group Policy No, State, and Zip Code.

step 3 to finishing STRS

You'll have to indicate the rights and obligations of each side in field Employer Name, Address, City, Phone No, State, Zip Code, Employment Start Date, Employment End Date, Are you selfemployed at any, Date you resumed parttime work, Date you resumed fulltime work, Work Phone, Work Phone, Extension, and Extension.

STRS Employer Name, Address, City, Phone No, State, Zip Code, Employment Start Date, Employment End Date, Are you selfemployed at any, Date you resumed parttime work, Date you resumed fulltime work, Work Phone, Work Phone, Extension, and Extension fields to fill

Finalize by looking at the next areas and filling them in accordingly: Standard Insurance Company CTA, Claimants Name, SICKNESS Please list all, Illness, Illness, State what you believe caused your, Describe your symptoms, Have you ever had the same, Date, Disability Insurance Employees, Date First Noticed, Date First Noticed, INJURY, Describe Injuries, and Cause of Injuries.

Entering details in STRS part 5

Step 3: As soon as you click the Done button, your finished document can be easily exported to any kind of your gadgets or to email indicated by you.

Step 4: It is easier to prepare copies of the file. You can rest assured that we will not publish or see your details.

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