Authorization To Disclose Information (West - Form United Health Care
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1
2AUTHORIZATION TO DISCLOSE
TRICARE WEST REGION
PURPOSE
This Authorization to Disclose form is filled out when you, the beneficiary, want to grant another individual or
organization access to your protected health information (PHI). Your PHI is protected by the Privacy Act, the Health
Insurance Portability and Accountability Act (HIPAA), state laws, and UnitedHealthcare policies and procedures. The
employees of UnitedHealthcare are trained to protect your information.
IDENTIFICATION OF INDIVIDUAL OR ORGANIZATION
The information that you provide in the first section of this form tells UnitedHealthcare to whom you want us to disclose
your PHI. Should you need to grant access to your PHI to more than one individual or organization, please use a separate
form for each.
INFORMATION TO BE DISCLOSED
In this section of the form, you tell us what information you are authorizing UnitedHealthcare to disclose to the individual
or organization you have named. You may choose to disclose all of your PHI maintained by UnitedHealthcare or, in a
written description, you can specify the information you want disclosed to the designated individual or organization.
EXPIRATION
This Authorization to Disclose is valid for one year (12 months) from the date you sign, if you do not enter a date in the
space provided.
AGREEMENT
Your rights regarding this Authorization to Disclose form are outlined in the “Agreement” section of the form. Please read
it thoroughly. You are required to sign the document in the “Signature” space provided.
PERSONAL REPRESENTATIVES
If you are having your “Personal Representative” prepare and sign this Authorization to Disclose form on your behalf, a
copy of the Power of Attorney or other legal documentation appointing the individual as your “Personal Representative”
must be attached to the form.
Please mail the completed and signed form to the following address:
UNITEDHEALTHCARE MILITARY & VETERANS
TRICARE WEST PRIVACY OFFICE
PO BOX 105661
ATLANTA GA 30348-5661
or
You may fax your completed and signed form to:
1-877-894-1493
1)
FOR OFFICIAL USE ONLY. THIS INFORMATION IS PROTECTED BY THE PRIVACY ACT OF 1974 AND SUBJECT TO THE HEALTH INFORMATION
PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF 1996.
UHCMV0624_032213v1
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