Authorization To Disclose Substance Use Treatment Information For Coordination Of Care printable pdf download

AUTHORIZATION TO DISCLOSE SUBSTANCE USE TREATMENT

INFORMATION FOR COORDINATION OF CARE

Name of Patient:

DOB:

Address:

Phone Number:

Medical Assistance Number:

Section 1:

Purpose of Authorization

This Authorization to disclose is for the purpose of permitting the Maryland Medical Assistance Program

(the Medicaid program), my substance use treatment provider, and any other providers identified in this

form to coordinate my care so that it is more beneficial to me. By giving my consent, my Medicaid

Managed Care Organization and any other providers specifically identified on this form will have access

to information about substance use treatment I am receiving, which will help avoid conflicts in

medication or treatment and improve the care I am receiving. By giving this consent, I may also gain

access to other case management services offered through the Medicaid program.

Section 2:

Name of Substance Use Treatment Provider [TO BE COMPLETED BY PROVIDER]

_____________________________________________________________________________

Address:_____________________________________________________________________________

____________________________________________________________________________________

Section 3:

Duration and Revocation of Authorization

I may revoke this Authorization at any time either verbally or in writing by informing my substance use

treatment provider of my wish to revoke authorization. I may also revoke this authorization by writing to

the Maryland Medicaid Program’s administrative services organization, ValueOptions Maryland, at:

ValueOptions, Inc.

EDI Helpdesk / PO Box 1287, Latham, NY 12110

Phone: 800.888.1965

Fax: 877.502.1044

This Authorization’s effective date is:

___. This Authorization expires when (1) I revoke

the Authorization; (2) I am no longer enrolled in a Medicaid Managed Care Organization; or (3) I

am no longer receiving treatment from a substance use treatment provider.

Section 4: Authorization

I hereby authorize my substance use treatment provider to disclose to the Maryland Medicaid Program

(including its administrative services organization, ValueOptions Maryland), claims and authorization

data resulting from my treatment, for purposes of coordination of my care. I also authorize the Maryland

Medicaid Program (including ValueOptions Maryland), to redisclose my claims and authorization data to

the Medicaid Managed Care Organization in which I am enrolled, and with any additional health care

providers listed on this form below, for purposes of coordinating my health care. I further authorize my

substance use treatment provider to disclose medical records requested by my MCO’s patient care

coordination team, for purposes of coordinating my care.

Authorization To Disclose Substance Use Treatment Information For Coordination Of Care