State Of Delaware Authorization For Release Protected Health Information Form

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STATE OF DELAWARE
A
F
R
O
P
H
I
UTHORIZATION
OR
ELEASE
F
ROTECTED
EALTH
NFORMATION
D
FROM THE
ELAWARE EMPLOYEE HEALTH CARE PLAN
[
-
]
PLEASE CHECK THE APPROPRIATE BOXES AND FILL
IN THE BLANKS
Section 1: Person whose health information will be disclosed: [please print]
Name ________________________________________________________________________
Address ______________________________________________________________________
City and State__________________________________________________________________
Health Plan ID No. _____________________________________________________________
Telephone Number _____________________________________________________________
Birth Date_____________________________________________________________________
Section 2: Person or Entity that has the health information to be released:
_________________________________________ [please print the name of the entity that has
the record to be disclosed; e.g., Dr. Jane Doe, XYZ Insurance Company, ABC Laboratories, etc.]
Section 3: Description of the health information to be released:
All information related to the claim for medical services or treatment described below.
Claim Number(s): ____________________ Date(s) of Service: __________________
Provider(s) Name: _______________________________________________________
If “information related to a sensitive” diagnosis is to be disclosed, the pertinent boxes must be
checked:
Substance Abuse
HIV/AIDS
Genetic Testing
Mental Health Care
[Please note that the types of information to be disclosed by the Plan include: explanation of
benefits (EOB) forms, claims history, eligibility determinations, information related to payment of
claims or coordination of benefits, medical records obtained and/or reviewed with regard to
claims or appeals, and other information that the Plan may have used to make decisions about
your eligibility for benefits or the payment of your claims.]
Section 4: Person or Entity that will receive the health information: Representatives of
Statewide Benefits Office and other State Delegates involved in the health plan appeal process.
Section 5: Description of the purpose for the release of the health information:
At the request of the person whose name appears in Section 1
To obtain assistance with adjudication, payment and/or appeal of pending Plan claims
To support a claim for non-health benefits, such as disability benefits, workers compensation
benefits or life insurance benefits
Other [insert description of the purpose]: ________________________________________
____________________________________________________________________________
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