Form Dhs 1123 - Authorization To Disclose Confidential Information
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1STATE OF HAWAII
Med-QUEST Division
Department of Human Services
P. O. Box 700190
Kapolei, HI 96709-0190
AUTHORIZATION TO DISCLOSE CONFIDENTIAL INFORMATION
BY THE Med-QUEST DIVISION (MQD)
(1) __________________________________________________________________________ (2) _______________________________________
PRINT Name: Last, First, Middle Initial (Applicant/Recipient/Legal Representative)
PRINT: Legal Representative's Authority
(Please check boxes below):
I authorize the MQD to provide the following information
(3)
:
Eligibility
Insurance Information
Payment History
Enrollment
Medical Claims Information
Prior Authorization
Other ________________________________________________ Service Dates: ______ / ______ / ______ to _____ / ______ / _______
Please initial in the spaces provided if you authorize disclosures of the following specially protected health information:
_______
_______
________
HIV/AIDS
Mental Health
Substance Abuse Treatment
about
: (4) ________________________________________________________ (5) _______________________ and/or ______ / ______ / ______
PRINT NAME: Last, First, Middle Initial
Social Security Number
Birth Date
(Month/Day/Year)
Of
To:
(6)
__________________________________________________
___________________________________________________________________________________________
PRINT Name of Person/Agency Authorized to Receive information
Relationship to Applicant/Recipient (if any)
(7) _______________________________________________________ ________________ _______ ___________
(8) ______________________________
Mailing Address
City
State
Zip Code
Telephone
This information will be used to:
____________________________________________________________________
(9)
This authorization is good for one year from the date you sign this form unless you tell us the following:
(10) Date ________ / ________ / _________ Or Event : _________________________________________________________________________
Month
Day
Year
I understand that:
a. I do not have to sign this form.
b. I can cancel this form by writing to the above address, except for the information that was already disclosed.
c. If I am an applicant and refuse to allow disclosure, this may affect my eligibility for coverage under the Hawaii State
Medicaid program.
d. If I am a recipient and refuse to allow disclosure of my protected health information, this may affect payment of my
claims if the disclosure information is necessary to determine payment of my claims
e. I can make a copy or check the information used or disclosed. If MQD knows who keeps the information, the MQD
will provide me the name and address of the company or provider.
f. I may have to pay a fee charged by the MQD to process the requested information.
_________________________________________________________
________/_______/________
Date:
(11)
(Signature of Applicant / Recipient / Legal Representative) **
Month
Day
Year
____________________________________________ ________________ _____ __________
Mailing Address
City
State
Zip Code
The information released under this authorization may be subject to re-disclosures by the authorized person (6) above
**
and the re-disclosure may not be protected under federal /state regulations.
FOR OFFICIAL USE ONLY:
UNIT:
WKR:
CID:
Date:
)
You may keep a copy for your records
DHS 1123 (Rev 11/06
Original - MQD Administration
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