Masshealth/casualty Recovery Unit Permission To Share Information (Psi) Form printable pdf download

Masshealth/casualty Recovery Unit Permission To Share Information (Psi) Form

MASSHEALTH/CASUALTY RECOVERY UNIT

PERMISSION TO SHARE INFORMATION (PSI) FORM

When to use this form:



Use this form if you want the Casualty Recovery Unit to share the information we have about you with another person or

organization, such as:

a family member, friend, or other relative;

an attorney representing you,

a social worker, lawyer, or health-care advocacy group;

an insurance company settling a case on your behalf.

Where to send this form:



If you are authorizing the sharing of only medical claims information send the PSI to:

Commonwealth of Massachusetts

Casualty Recovery Unit

P. O. Box 15205

Worcester, MA 01615-0205

Fax: 1-508-856-7672

Name of MassHealth member:

Section 1

Permission is given for the Casualty Recovery Unit and its representatives to share information listed in Section 2 about:

(Name of member whose information is to be shared)

Street

City/State/Zip

Date of Birth

Telephone number

MassHealth ID number

Please note:

If you do not have a MassHealth ID number, please use your social security number.

Masshealth/casualty Recovery Unit Permission To Share Information (Psi) Form