Massachusetts General Laws
Chapter 175i - Insurance Information and Privacy Protection
Section 6 - Disclosure Authorization Form; Contents

Section 6. Notwithstanding any general or special law to the contrary, no insurance institution, insurance representative or insurance-support organization may utilize as its disclosure authorization form in connection with insurance transactions a form or statement which authorizes the disclosure of personal or privileged information about an individual to the insurance institution, insurance representative or insurance-support organization unless the form or statement:
(1) is written in plain language;
(2) is dated;
(3) specifies the types of persons authorized to disclose information about the individual;
(4) specifies the nature of the information authorized to be disclosed;
(5) names the insurance institution or insurance representative and identifies by generic reference the representative of the insurance institution to whom the individual is authorizing information to be disclosed;
(6) specifies the purposes for which the information is collected;
(7) specifies the length of time such authorization shall remain valid, which shall be no longer than:
(A) in the case of authorizations signed for the purpose of collecting information in connection with an application for an insurance policy, a policy reinstatement or a request for change in policy benefits, thirty months from the date the authorization is signed; or
(B) in the case of authorizations signed for the purpose of collecting information in connection with a claim for benefits under an insurance policy:
(i) the term of coverage of the policy if the claim is for a health insurance benefit; or
(ii) the duration of the claim if the claim is not for a health insurance benefit; and
(8) advises the individual or a person authorized to act on behalf of such individual that such individual or the individual's authorized representative is entitled to receive a copy of the authorization form.

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