Banner Life – Important Reminder Regarding Forms

Important Reminder – March 2, 2018

Apps without current or complete HIPAA forms are being rejected

The Authorization to Obtain and Disclose Information forms (“HIPAA” forms) for Banner and William Penn were updated twice in the past eighteen months. They were updated most recently in the first quarter of 2017, at which time you were notified that we would accept the prior HIPAA forms until April 24, 2017.

We are currently rejecting a large number of applications daily because agencies are either sending outdated HIPAA forms or not including them at all. This is delaying service for your customers because we cannot begin underwriting unless we have a current HIPAA form that is fully completed and signed.

The HIPAA form and the application should be sent together. Please treat the form as an additional page of the application. It otherwise goes to our New Business queue to be set up as unmatched mail which results in delays or rejection.

Among the important changes to the form were enhanced lists of sources from which we may obtain personal information and the types of information collected. The new form is more transparent and promotes a better understanding of the Authorization by the Proposed Insured.


Please discontinue use of any now-obsolete consent forms and update any online posting. The current HIPAA form is available on the Partner Dashboard. Type HIPAA or LU1250 in the search bar and look for your state-specific form.

To download the HIPAA PDFs without logon, use these links:

LU1250  Release of Health-Related Info (HIPAA)  CA, CT, DC, DE, ND, SD Banner

LU1250WP NY Release of Health-Related Information (HIPAA) Penn

ICC17 LU1250ME  ME Release of Health-Related Information (HIPAA) Banner

ICC17 LU1250VT  VT Release of Health-Related Information (HIPAA) Banner

LU1250FL  FL Release of Health-Related Information (HIPAA) Banner

ICC17 LU1250 ALL OTHER STATES Release of Health-Related Information (HIPAA) Banner

We also added “genetic information and genetic testing results” to the LU1282 reinstatement application PDF packages that contain the HIPAA form.  Log on to the Partner Dashboard and type LU1282 in the search bar and look for your state-specific form. Uncheck “Only new application forms” since this is a reinstatement app rather than a new app.

All form vendors have been notified for implementation.


Have a question? 
Please contact a member of your new business team.