Your provider will use this form to get your permission to share your protected health information with a third party for personal use, insurance, continued medical care, or other reasons. You do not have to sign this form as it is voluntary. If you do not sign the authorization form, we will not release protected health information to a third party.
Please complete the form and email it to firstname.lastname@example.org. You may also fax it to 1-866-722-1180 or mail it to:
MetLife Long Term Care Claims
PO Box 14407
Lexington, KY 40512