Authorization To Disclose Substance Use Treatment Information For Coordination Of Care Page 2

ADVERTISEMENT

I understand that the information that may be disclosed as a result of this authorization may not be re-
disclosed to any entity other than those entities identified in this authorization.
I have been provided a copy of this Authorization.
Patient Signature
Date
Parent or Guardian Signature* (if applicable)
Date
Additional health care provider(s) with whom information about my care may be shared:
Name:______________________________________________________________________________
Address:_____________________________________________________________________________
____________________________________________________________________________________
Name:______________________________________________________________________________
Address:_____________________________________________________________________________
____________________________________________________________________________________
* NOTE: If you are signing as the member’s Legally Authorized Representative, attach a copy of the
legal document(s) granting you the authority to do so. Examples are a health care power of attorney, a
court order, guardianship papers, etc.
The following are the Maryland Medicaid Managed Care Organizations (MCOs):
Amerigroup Community Care
MedStar Family Choice
Compliance Officer
Compliance Officer
7550 Teague Road, Ste 500
8094 Sandpiper Circle, Ste O
Hanover, Maryland 21076
Baltimore, MD 21236
410-859-5800
410-933-3014
Jai Medical Systems
Priority Partners
Compliance Officer
Compliance Officer
5010 York Road
Baymeadow Industrial Park
Baltimore, MD 21212
6704 Curtis Court
410-433-2200
Glen Burnie, MD 21060
410-424-4400
Kaiser Permanente
Compliance Officer
Riverside Health of Maryland
2101 East Jefferson Street
Compliance Officer
Rockville, MD 20852
1966 Greenspring Dr., 6th Floor
301-816-2424
Timonium, MD 21093
410-878-7709
Maryland Physicians Care
Compliance Officer
UnitedHealthcare
509 Progress Drive
Compliance Officer
Linthicum, MD 21090-2256
Lyndwood Executive Center
800-953-8854
6095 Marshalee Dr., Ste 200
Elkridge, MD 21075
410-379-3457

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 2