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Alaska Department of Administration, Retirement and Benefits

Department of Administration

Division of Retirement and Benefits

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Administration > Division of Retirement and Benefits > Health and Optional Benefits > Retiree > Forms > Disclosure Authorization
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Disclosure Authorization Form

Health information disclosure authorization form
Authorization for Use & Disclosure of Protected Health Information (PHI) form ben043 [PDF]

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Division of Retirement and Benefits
6th Floor State Office Building, P.O. Box 110203, Juneau, AK 99811-0203
Fax: (907) 465-3086 • TDD: (907) 465-2805 • Telephone: (907) 465-4460 • Toll-Free: (800) 821-2251
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