Skip to main content
State of Alaska
  • myAlaska
  • My Government
  • Resident
  • Business in Alaska
  • Visiting Alaska
  • State Employees
  • Statewide links
Alaska Department of Administration, Retirement and Benefits

Department of Administration

Division of Retirement and Benefits

  • Sections
    • DRB Home
    • Retirement
    • Benefits
    • Employer Services
    • AlaskaCare
    • Easy Navigation
  • Categories
    • Health
    • Long-Term Care
    • Life
    • Forms
    • Publications
    • FAQs
  • Features
    • Great-West Account Info Online
    • myRnB Member Services
    • Seminars
    • AlaskaCare Wellness
    • Forms & Brochures
    • Headlines
    • Get My RIN
  • DRB Home
  • Retirement
  • Benefits
  • Employer Services
  • AlaskaCare
  • Easy Navigation
  • Retiree
  • Health
    • AlaskaCare Retiree Health
    • Coverage Changes
    • Medicare Info
  • Long-Term Care
  • Life
    • Life Premiums
    • Select/Optional Life
    • Death Benefits
  • Forms
    • Enrollment/Change
    • Disclosure Authorization
    • Life Insurance Forms
  • Publications
    • Booklets
    • Financial Statements
    • Retiree Tax Implications
  • FAQs
Administration > Division of Retirement and Benefits > Health and Optional Benefits > Retiree > Forms > Disclosure Authorization
  • Great-West Account Info Online
  • myRnB Member Services
  • Seminars
  • AlaskaCare Wellness
  • Forms & Brochures
  • Division Headlines
  • Get My RIN
 

Disclosure Authorization Form

Health information disclosure authorization form
Authorization for Use & Disclosure of Protected Health Information (PHI) form ben043 [PDF]
Sign Up to Receive News & Updates

Changes

  • Address Changes
  • Apply for Retirement
  • Insurance Enrollment
  • Rollovers

Education

  • AK Retirement Management Board
  • Glossary
  • Video Tutorials

General

  • All Programs at a Glance
  • Contact Us
  • Mission Statement

Requests

  • Alternative Format Request
  • Customer Service Request Status
  • Refund Requests

Resources

  • Benefit Mailing Dates
  • Booklets
  • CAFRs
  • Valuations

Tools

  • Net Pay Estimator
  • Retiree Net Pay Estimator
  • Retirement Links
Sign up for news and updates
  • Accessibility
  • Contact
  • Policies
  • Site Index
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
  • State of Alaska
  • myAlaska
  • My Government
  • Visiting Alaska
  • Business in Alaska
  • Resident
  • Employee
State of Alaska © 2013  Webmaster

Back to top