Form Dhs 1124 Authorization To Disclose 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
TO THE Med-QUEST DIVISION (MQD)
(1) _____________________________________________________________
(2) __________________________________________________
PRINT Name: Last, First, Middle Initial
PRINT Legal Representative's Description of Authority
I authorize
_______________________________________________________ to provide the following information
(3)
:
PRINT Name of Person/Agency Authorized to Disclose Information
(Please check boxes below):
Medical Records
Insurance Information
Payment History
Enrollment
Medical Claims Information
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 _____ / _____ / ______
Social Security Number
Birth Date
PRINT NAME: Last, First, Middle Initial
(Month/Day/Year)
To the Hawaii Dept of Human Services, Med-QUEST division.
Contact Name : ____________________________
(6) _______________________________________________________ _________________ _______ ___________
(7) __________________________
Mailing Address
City
State
Zip
Telephone
This information will be used to:
___________________________________________________________________
(8)
This authorization is good for one year from the date you sign this form unless you tell us the following:
(9) Date ________ / ________ / _________ OR Event: ________________________________________________________________________
Month
Day
Year
I understand that:
a. If I do not sign this form, Med-QUEST will not get the information you requested.
b. I can cancel this form by writing to the above named (3) above, except for the information that was already disclosed.
c. If I am applying for Medical assistance and refuse to allow disclosure, it 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, it may affect payment of my
claims if the disclosure is necessary to determine the payment of my claims.
e. I can receive a copy or check the information used or disclosed.
f. I may have to pay a fee to process the requested information.
_____________________________________________________
___________/_________/ ________
(10)
(Signature of Applicant / Recipient / Legal Representative)
Date: Month
Day
Year
____________________________________________ ________________ _____ _________
Mailing Address
City
State
Zip Code
FOR OFFICIAL USE ONLY:
UNIT:
WKR:
CID:
Date:
)
You may keep a copy for your records
DHS 1124 (Rev. 11/05
Copy - MQD Administration
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