Consent For Release Of Protected Health Information (Phi) Form
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1Consent for release of protected health information (PHI)
This form is used to authorize consent for Humana to communicate PHI to the person or organization below.
Member information (person whose information will be released):
Name: _____________________________________________________ Date of birth: ________ / _____/ _________
First
Middle
Last
Month
Day
Year
Address: _________________________________________________________________________________________
Street
City
State
ZIP
Member ID: _________________ Group # (if applicable): _________________Phone #: _______________________
q Home
q Cell*
I understand that this authorization will allow Humana and its affiliates to use or disclose the protected
health** information described below: (Please check only one box)
q Full Disclosure: Any protected health information Humana and its affiliates maintains, including mental
health, HIV, health status or substance abuse records. This also includes sharing information on mail-order
pharmacy, wellness products, and health programs with the person being authorized.***
q Limited Disclosure: You specify what PHI to share. Ex. condition or treatment information, a specific date
range, or product type. Unless you limit by product type, information will apply to all products and services. __
_________________________________________________________________________________________________
If Limited Disclosure was selected please indicate which product(s) apply: q Medical and/or Prescription
q Vision q Dental q RightSource (becomes Humana Pharmacy in June 2015) q HumanaVitality
This information may be disclosed to, and used by, the following person or organization (such as nursing home
or care provider) to assist me with the Humana-owned products or services for which I am providing consent
to disclose information:
Name: _____________________________________________________ Date of birth: ________ / _____/ _________
First
Last
Month
Day
Year
Middle
Or if organization: _________________________________________________________________________________
Name
Address: _________________________________________________________________________________________
Street
City
State
ZIP
Email: _________________________________________ Phone #: _________________________________________
q Home q Cell*
Relationship: q Spouse
q Sibling
q Parent
q Child
q Agent/Broker
q Friend
q Organization
I understand:
· My consent will expire in 24 months unless I cancel it before that time. I can cancel my consent through my
MyHumana account or by submitting a written notice to Humana.
· If I cancel consent, it will not apply to any information previously released with this authorization. Once
information is shared, Humana cannot prevent the person or organization who has access to it from sharing
that information with others, and this information may not be protected by federal privacy regulations.
· I am not required to sign this consent and Humana cannot base decisions regarding treatment or payment
on whether I sign it.
Member or Legal Representative signature ____________________________________Date: ____ / ____ / _____
q Member q Legal Representative
Please note: Legal representatives must attach copies of authorization as required by law. Examples
include healthcare power of attorney, healthcare surrogate, living will or guardianship papers.
After you complete and sign the form, please fax it to 1-800-633-8188. OR If you prefer, mail your
completed form to: Humana Insurance Company, P.O. Box 14168, Lexington, KY 40512-4168
* By giving your cell phone number, you give Humana permission to make calls to your cell
** Health includes Medical, Dental, Pharmacy, Behavioral Health, Vision, Long-Term Care
*** Includes web access when available
Humana will follow the more stringent of all federal and state laws and regulations.
GNHJ5Y5EN 0115
For Humana Use Only
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