Member Authorization Form printable pdf download

State of New Jersey - Department of the Treasury

Return to: HIPAA Privacy Officer

HB-0627-0503q

State Health Benefits Program

Division of Pensions and Benefits

PO Box 295

STATE HEALTH BENEFITS PROGRAM

Trenton, NJ 08625-0295

MEMBER AUTHORIZATION FORM

FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Member’s Name: __________________________________________________________________________________

LAST

FIRST

Address:

_______________________________________________________________________________

Daytime Telephone Number: ( _______ ) ________________ E-mail: _______________________________________

AREA CODE

Member’s Social Security Number: ________________________________________ Date of Birth: ______/_____/______

YYYY

By signing this form I authorize the State Health Benefits Program (SHBP) to use and/or disclose my health information

(information that constitutes protected health information as defined in the Privacy Rule of the Administrative

Simplification provisions of the Health Insurance Portability and Accountability Act [HIPAA] of 1996) in the manner

described below. The SHBP will not condition treatment, payment, enrollment in a health plan, or eligibility for health care

benefits on my decision to sign this authorization.

I have signed this form voluntarily to document my wishes regarding the use and/or disclosure of the health infor-

mation described below.

1. Description of Health Information I Authorize to be Used or Disclosed. The following is a specific description of

the health information I authorize be used and/or disclosed:

_________________________________________________________________________________________________

2. Description of Each Purpose for the Requested Use and/or Disclosure. I authorize my health information to be

used and/or disclosed for the following specific purposes:

_________________________________________________________________________________________________

3. Persons/Organizations Authorized to Receive and/or Use My Health Information. I authorize the following per-

son(s) and/or organization(s) to receive my health information from the SHBP and to use or disclose such information for

the purposes listed above. I understand that the health information disclosed pursuant to this authorization may no longer

be protected by the federal privacy standards and may be redisclosed without obtaining my authorization.

_________________________________________________________________________________________________

Continued on next page

Fax on Demand #9007

Member Authorization Form