Authorization To Disclose Information (West - Form United Health Care Page 2
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2AUTHORIZATION TO DISCLOSE – TRICARE WEST REGION
Please reference Instructions page and complete all appropriate areas.
Name of Beneficiary ___________________________________________________________________________,
Beneficiary Contact Telephone ______________________________
Sponsor DoD Benefit Number _______________________ or Social Security Number ______________________,
hereby authorizes UnitedHealthcare and its business associates to disclose my PHI to:
Name of Individual/Organization __________________________________________________________________
Relationship to Beneficiary _______________________________________________________________________
Address ______________________________________________________________________________________
City/Town___________________________________________ State ________________ Zip _________________
Contact Telephone ________________________________ Fax number (If Available) ________________________
Email Address (If Available) ______________________________________________________________________
Information to be Disclosed (Check all that Apply):
Medical/Surgical Information
Claims Information
Mental Health/Substance Abuse Information
(Does Not Include Psychotherapy Notes)
Other (Please Specify): ________________________________________________________________________
______________________________________________________________________________________________
The Purpose for Disclosing Your PHI
□
To provide information at the request of the individual or organization named above.
□
To resolve a claims or payment issue.
□
Other (Please Specify): ________________________________________________________________________
Expiration Date: ______________________
If no expiration date is entered, the expiration date will be one year from the date this form is signed.
Agreement: I understand that I may revoke this authorization at any time by submitting my revocation in writing to
UnitedHealthcare. I am aware that the recipient named above may also further disclose my PHI according to his/her/their
policies and practices and that my PHI may no longer be protected by HIPAA.
I further understand that UnitedHealthcare may not condition treatment, payment, enrollment or eligibility for benefits on
my signed submission of this authorization. I am entitled to keep a copy of this form for my records.
________________________________________________
____________________________________
Signature of Beneficiary/Requestor
Date
I am a personal representative of the above named Beneficiary and have attached proof of this relationship to this
form (Power of Attorney [POA] or other legal documents).
________________________________________________
Signature of Beneficiary’s Personal Representative
________________________________________________
_____________________________________
Print Name of Beneficiary’s Personal Representative
Date
2)
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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