Group Disability Authorization to disclose information about me Metropolitan Life Insurance Company Things to know before you begin • Section 2 requires your signature. • Return this form as soon as possible to expedite processing of your claim as described in How to submit section at the end of the form and keep a copy for your records. Your refusal to complete • If you are the Authorized Representative, include a copy of the legal and sign this form may document(s) authorizing you to act on the Claimant’s behalf and affect your eligibility for include the claim number at the top of each page. benefits. HIPAA: This Authorization has been carefully and specifically drafted to permit disclosure of health information consistent with the privacy rules adopted and subsequently amended by the United States Department of Health and Human Services pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). NOTE TO ALL HEALTH CARE PROVIDERS: 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. SECTION 1: Claimant information First name Middle name Last name Date of birth (mm/dd/yyyy) Claim number ID number (If applicable) SECTION 2: Authorization & signature For purposes of determining my eligibility for disability benefits or request for reasonable accommodation under the Americans with Disabilities Act (ADA), the administration of my disability benefit plan (which may include assisting me in returning to work, or applying for Social Security Disability Insurance benefits), and the administration of other benefit plans in which I participate that may be affected by my eligibility for disability benefits, including but not limited to any Workers’ Compensation, employee assistance or disease management program, I permit the following disclosures of information about me to be made in the format requested, including by telephone, fax or mail: 1. I permit: any physician or other medical/care provider, hospital, clinic, other medical related facility or service, pharmacy benefit administrator, insurer, employer, government agency, group policyholder, contract holder or benefit plan administrator to disclose to Metropolitan Life Insurance Company (“MetLife”), and any consumer reporting agencies, investigative agencies, attorneys, and independent claim administrators acting on MetLife’s behalf, any and all information about my health, medical care, employment, and disability claim. 2. I permit: MetLife to disclose to my employer or its agents acting in the capacity of administrator of its benefit plans or programs, including but not limited to, Workers’ Compensation, employee assistance, or disease management programs, any and all information about my health, medical care, employment, and disability claim. Page 5 of 9 EES-LTD-5323 (08/20) Fs/f