SFDC: 500Kh00000VsWETIA3 E117 vs 10.

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Authorization to Obtain and Disclose Information

Instructions for Employee: Complete and return to Amazon Disability & Leave Services (DLS).
Return the form: Upload the completed form to the DLS Portal, found on the Amazon AtoZ Resources page or at
dls.idp.amazon-corp.com (while on the Amazon network). You can also email to [email protected] or fax to
1-855-579-1799.
Employee Name: Woelamo Ambilo Employee Date of Birth: March 12, 1982
Employee ID: 102440892

This Authorization is being provided so that Amazon and any of its parents, affiliates, subsidiaries, and/or third-party
contractors; Aetna Inc. (Aetna), and any of their parents, affiliates, subsidiaries, and/or third-party contractors; The
Hartford, and any of their parents, affiliates, subsidiaries, and/or third-party contractors; Amazon Corporate LLC
(together with any of its Affiliates or Subsidiaries (Amazon); WorkCare, and any of its parents, affiliates, subsidiaries,
and/or third-party contractors; and/or Sedgwick Claims Management Services, Inc. (Sedgwick CMS) can obtain
the necessary information to adjudicate a claim for disability or workers’ compensation benefits, or a request for
leave of absence or related benefits, initiated by or on behalf of the Patient identified above (“Patient”). Once this
Authorization is completed and signed by the Patient (or Patient’s guardian) whose personal health information is to
be disclosed, the health care provider should retain the original for its records and provide a copy of the Authorization
to the Patient. Patient can submit completed document via the DLS Portal, by faxing to 1-855-579-1799, by
emailing [email protected], or by mail to Amazon Disability & Leave Services (DLS), PO Box # 81103 Address:
5801 Postal Road, Cleveland, Ohio 44181.
To: Any health care provider, Pharmacy Benefit Manager, employer, benefit plan, insurer, financial institution,
consumer reporting agency, educational institution, or federal, state, or local government agency, including the Social
Security Administration and Veterans’ Administration.
By signing the Patient Authorization below, your Patient has authorized you to disclose to Amazon, Aetna, The
Hartford, WorkCare, or Sedgwick CMS a complete copy of any and all personal or privileged information, records, or
documents described herein.
Information covered by this authorization: Any and all medical (but not genetic) information or records, including
X-ray films, prescription histories, medical histories, physical, mental or diagnostic examinations, and treatment notes,
and including information regarding HIV/AIDS, communicable diseases, alcohol or drug abuse, and mental health, as
such information may be related to the Patient’s claim for benefits; work information and history, including job duties,
earnings and personnel records, and client lists; information on any insurance coverage and claims filed, including all
records and information related to such coverage and claims; Social Security benefits information, including monthly
benefit amounts, monthly payment amounts, entitlement dates, and information from my Master Beneficiary Record.
The information obtained by use of this Authorization will be used to evaluate and administer the Patient’s claim for
benefits under the employer’s plan for short-term disability benefits or long-term disability benefits insured by Aetna
or The Hartford, to administer the Patient’s claim for workers’ compensation benefits, and/or a request for leave of
absence or related benefits. Such information is referred to in the Patient Authorization as “My Information.”
PATIENT AUTHORIZATION
I authorize Amazon, Aetna, The Hartford, WorkCare, or Sedgwick CMS to use or disclose My Information as necessary
to administer my claim for short-term disability benefits and/or workers’ compensation benefits and/or leave of
absence or related benefits. I also authorize Amazon, Aetna, The Hartford, WorkCare, or Sedgwick CMS to disclose My
Information as follows: (i) to Amazon for (a) functions related to accommodating my medical restrictions or limitations;
(b) federal or state Family & Medical Leave Act administration; (c) administration of related leave or benefits claims;
(d)fulfilling fiduciary obligations under my benefit plan or (e) responding to legal claims against Amazon or its agent;
(ii) to the administrator or other service providers of Amazon’s benefit plan or other benefit plans of my employer for
plan-related functions; (iii) to any system used for claims processing or insurance broker to carry out functions related
to my benefit plan or claim; (iv) to any health care professional who has treated or evaluated me or who may do so; (v)
to other persons or entities performing business or legal services related my claim or to other benefits for which I may
be eligible in the future; (vi) as may be lawfully required; (vii) as I may further authorize; or (viii) as necessary to prevent
or to detect perpetration of a fraud in connection with my application for benefits.
I authorize the disclosure of my personal and medical information as described above. I understand that this
authorization is voluntary. I understand that information disclosed pursuant to this Authorization may be subject to
Return this form via one of the following methods:
DLS Portal on the Resources page on Amazon AtoZ or on https://dls.idp.amazon-corp.com (on the network),
Email to [email protected] or Fax to 1-855-579-1799

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SFDC: 500Kh00000VsWETIA3 E117 vs 10.18 07991044

re-disclosure by the recipient as permitted by applicable law or my further authorization. I understand that I have the
right to fully or partially revoke this Authorization for future disclosures from Amazon, Aetna, WorkCare, or Sedgwick
CMS may make, unless they have taken action in reliance upon this Authorization. If I decide to fully or partially
revoke my Authorization, I must revoke do so in writing directly to Amazon, specifying whether I wish to fully revoke
my authorization, or, if I wish to partially revoke my authorization, providing a description of the information and/
or purposes for which I am withdrawing my authorization. I understand that my medical treatment, payment for
medical benefits, or enrollment/eligibility for leave benefits cannot be conditioned on my allowing Amazon, Aetna,
the Hartford, WorkCare, or Sedgwick CMS to re-disclose My Information and that I may fully or partially revoke my
authorization for re-disclosure at any time.
This Authorization expires two years from the date listed below or earlier as required by law, or upon my revocation,
if earlier, but will not exceed the term of my coverage of the policy or benefit plan. I understand that I am entitled to
receive a copy of this Authorization upon request. A photocopy or facsimile of this Authorization shall be as valid as
the original. If there is a conflict between a prior request for restriction on the disclosure of My Information and this
Authorization, this Authorization will control.
Note to employee/beneficiary: In order to be considered for short-term disability or workers’ compensation
benefits, you must authorize disclosure of personal and medical information as needed to determine whether you
qualify for those benefits. If signed, this form would also authorize further disclosure of your information in order to
expedite consideration of your eligibility for additional benefits in the future. Such additional benefits might include
long-term disability benefits, vocational rehabilitation services, and payment of life insurance premium while you are
on leave. You are not required to authorize disclosure or re-disclosure of your personal or medical information for
such additional purposes. If you do not want this release to authorize such additional disclosure, please contact DLS at
1-888-892-7180.
Important Information for Your Health Care Provider About GINA
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by
GINA Title II from requesting or requiring genetic information of an individual or family member of the individual,
except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic
information when responding to this request for medical information. "Genetic Information" as defined by GINA
includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact
that an individual or an individual's family member sought or received genetic services, and genetic information of a
fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family
member receiving assistive reproductive services.

___________________________________ ___________________________________ ________/___________/__________

Signature of Patient or Guardian Relationship to Patient Date Signed
(if signed by guardian)

Return this form via one of the following methods:

DLS Portal on the Resources page on Amazon AtoZ or on https://dls.idp.amazon-corp.com (on the network),
Email to [email protected] or Fax to 1-855-579-1799
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