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

Masshealth/casualty Recovery Unit Permission To Share Information (Psi) Form Page 3

End of Permission

Section 5

This PSI will end in 18 months unless you specify an end date here. ________________________

Your Signature

Section 6

I understand the following:

When the person or organization named in Section 3 gets this information from the Casualty Recovery Unit, that person or

organization may be able to share it with others without my permission. If they do so, federal and state privacy laws may

not protect the information.

I need to send this PSI to the address on the front page.

I may cancel this permission at any time by sending a letter to:

Casualty Recovery Unit, P.O. Box 15205, Worcester, MA 01615-0205

Even if I cancel this permission, the Casualty Recovery Unit cannot take back any information that it shared when it had my

permission to do so.

If I do not give the Casualty Recovery Unit Permission to share information, or if I cancel my permission to share

information with the person or organization named in Section 3, my MassHealth benefits will not be affected in any way.

____________________________________

Name of Member (Print)

Signature of Member

Date

Signature/Legal Guardian

Section 7

Fill out the following section if this form is being filled out by someone who has the legal authority to act on behalf of the

applicant or member (such as the parent of a minor-child, an eligibility representative, or a legal guardian).

Printed name of person filling out this form

Signature of person filling out this form

Date

Address

Telephone number

Authority of person filling out this form to act on behalf of member.*

*If this form is being filled out by someone who has been appointed by a court as a legal guardian or conservator or who has

power of attorney or health-care proxy, a copy of the applicable legal document must be attached.

Masshealth/casualty Recovery Unit Permission To Share Information (Psi) Form Page 3