authorization to release personal information · 2017-10-31 · authorization to release personal...

Authorization to Release Personal Information

A. Member Information ( Please Print)

Last Name: First Name: Gender: Male Female

Address: Birth Date (m/d/y):

Town/City: Province: Postal Code:

Union ID or Social Insurance Number (SIN): Telephone #:

Email Address: Cell #:

Married/Common-Law Single Marital Status: Plan:

B. Person of AuthorizationIn the boxes below, please list the relationship status, name and birth of all individuals

Relationship to Member Birth Date Contact Information Name of Authorized (spouse, child etc.) Day Month Year

C. Disclosure Member AuthorizationI am a member of the Labourers' Union Local 506 Construction Division Employee Benefit Trust Fund/Labourers' Union Local 506 Industrial Division Employee Benefit Trust Fund and I do hereby request that the Local 506 Trust Administration office release in writing, details of my personal health related information. I hereby consent to the disclosure of my personal information to the following individuals listed above.

As the authorized representative receiving the above members’ personal information, I agree to keep the personal information entrusted to me private and confidential.

This consent is valid: (Choose ONE only)

For this request only

For a period of one year

Until I withdraw the consent or cease to be a member/beneficiary of the fund

Member Name: Member Signature: (Please Print)

Date:

Submit to: LiUNA Local 506 Trust Administration I 3750 Chesswood Dr. - Suite 1 I Toronto, ON M3J 2W6 I Tel: (416) 506-8841 I Email: info@506membersbenefits.ca

Please complete, print, sign, and return by fax: (416) 506-8833 or by email at info@506membersbenefits.ca

Construction Industrial