Authorization To Release Confidential Information printable pdf download

Authorization for Beacon Health Options to

Release Confidential Information

Important: By completing all sections of this form you allow Beacon Health Options, Inc. (Beacon) to disclose health care

information to the individuals you identify for up to one year. Completion of this form allows Beacon to share information with

your family, providers, legal representative, or anyone that you wish to have access to this information. Please fill in all sections

as incomplete forms may be returned.

Please note: It is also important for your doctor to have access to your medical information to ensure you receive the

best care possible. The purpose of sending the health information to your doctor is to assist in identifying any follow-up

medical care that may be needed. To allow us the ability to send your health information to your doctor, complete and

sign the release of information below. We will only send information that pertains to your care.

SECTION 1: IDENTIFY THE PERSON WHOSE INFORMATION IS TO BE RELEASED

(Member Name) authorize Beacon Health Options, Inc. (or any

________________________________________________________________

Beacon Health Options subsidiary holding my information) to disclose my health care information as described below.

Additional Member Identifying Information

Member ID#: ______________________

DOB: ____/____/____

Phone Number: _____________________

Name of Health Plan: _____________________________

SECTION 2: IDENTIFY THE PERSON, PROVIDER, OR ENTITY TO RECEIVE THE INFORMATION

Print the Name(s) of person or organization who will be receiving my information and contact information (if known):

_________________________________________________________________________________________________

Phone Number of the Recipient: _______________________________________________

SECTION 3: IDENTIFY THE REASON WHY THE INFORMATION SHOULD BE RELEASED (THE REASON

MAY BE “AT MY REQUEST”)

Reason: _______________________________________________________________________________________________

If known:

Care Coordination/Management

Claim Assistance

Quality of Care Review

Other (Please explain reason):

SECTION 4: IDENTIFY WHAT HEALTH INFORMATION MAY BE RELEASED

BY INITIALING the following items, you are authorizing Beacon to release the following specific types of

information to the person(s) identified in Section 2 above:

____ Mental health information and/or records (INITIALS REQUIRED!)

____ Alcohol or substance use information and/or records (INITIALS REQUIRED!)

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Authorization To Release Confidential Information