Masshealth/casualty Recovery Unit Permission To Share Information (Psi) Form (Page 2 of 3) in pdf

Masshealth/casualty Recovery Unit Permission To Share Information (Psi) Form Page 2

What information do you want shared? Please be aware that the information you are requesting us to

Section 2

share on your behalf may include financial information.

Check the box or boxes that apply.

□

am giving the Casualty Recovery Unit permission to share MassHealth Claims information pertaining to my accident which includes

MassHealth claims from: __________________ to ___________________

(month/year)

(month/ year)

□

other

(please be specific)

By giving the Casualty Recovery Unit this permission to share information, are you also giving the Casualty Recovery Unit

permission to share drug and alcohol treatment information?

□

Yes

, Share drug and alcohol treatment information.

□

, Do not share drug and alcohol treatment information.

Whom do you want us to share information with?

Section 3

List the name of ONLY ONE person or organization in this section. You must fill out another PSI form if you want to name more

than one person or organization.

Casualty Recovery Unit may share the information listed in Section 2 with

Name of Person or Organization

In care

of (name of person in organization to whom mail should be sent)

Street

City/State/Zip

Telephone number

Fax Number

Casualty Recovery Unit relies on the contact information you provide. Please be certain this contact information is correct.

Why do you want us to share your information?

Section 4

Tell us why you want to share the information listed in Section 2. If you leave this section blank, we will assume “at my

request.”

Masshealth/casualty Recovery Unit Permission To Share Information (Psi) Form Page 2