Authorization To Release Information printable pdf download

Authorization to Release Information

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This form is used to release your protected health information as required by federal and state privacy laws. Your authorization allows

the Health Plan (your health insurance carrier or HMO) to release your protected health information to a person or organization that you

choose. You can revoke this authorization at any time by submitting a request in writing to the Health Plan (contact Member Services for

further instructions). Revoking this authorization will not affect any action taken prior to receipt of your written request.

Member Information:

(individual whose information will be released)

Name:

Date of Birth:

(First, Middle, Last, Title)

(Month/Day/Year)

Address:

Telephone Number:

)

(including zip code)

(including area code

Group Name/Number:

Social Security Number: (optional)

Member ID Number:

(if available)

Health Plan:

(organization that will release your information)

I authorize ______________________________________ to release my protected health information as described below.

(Health Plan name on your ID card)

Recipient:

(person or organization that will receive your information)

Person’s Name or Organization:

Telephone Number:

)

(including area code

Address:

Fax Number:

(including zip code)

(if available)

Description of the Information to be Released:

(what type of information will be released)

Check only one box:

– Federal law requires

Psychotherapy notes

an authorization to use or release psychotherapy notes.

If you check this box, you may not check another box below.

All information related to the provision of and payment for my health care benefits or services.*

Specific information described below:*

______________________________________________________________________________________

Examples: The claim related to my service on (date); Appeal information related to my claim on (date)

Purpose of Release:

_________________________________________________________________________

Examples: At my request; To resolve my appeal; To assist with my health insurance services

*NOTE: State law requires that you give specific permission to release the information below even if you checked a box

above. Indicate your permission for the Health Plan to release any of the following information by initialing all that apply.

Genetic Information

___________

HIV/AIDS

___________

(Initials)

Substance/Alcohol Abuse

___________

Mental/Behavioral Health ___________

(Initials)

Expiration:

(when this authorization will end)

This authorization will expire on ____/____/____(mm/dd/yyyy) OR on the occurrence of the following event:

_____________________________________________________________________________________________

Examples: Until I revoke this authorization; Resolution of a specific issue

Approval:

(You OR your personal representative must sign and date this form in order for it to be complete.)

I understand that this authorization to release information is voluntary and is not a condition of enrollment in this Health Plan, eligibility

for benefits, or payment of claims. I also understand that if the person or organization I authorize to receive the information described

above is not subject to federal health information privacy laws, they may further release the protected health information and it may no

longer be protected by federal privacy laws.

Member Signature:

Personal Representative Information:

A personal representative is a person

By signing below, I authorize the use of my

who has the legal authority to act on behalf of an individual. A copy of a Power of Attorney

protected health information.

or other court-related legal document must be on file at the health plan.

________________________________

____________

____)___________

(

_____________________________

(Printed Name of Personal Representative)

(Date)

(Telephone Number)

(Signature of Member)

_____________________

______________________________

________________________________

(Date)

(Signature of Personal Representative)

(Description of representative’s authority)

08161

PLEASE KEEP A COPY OF THIS FORM AND THE INSTRUCTIONS FOR YOUR RECORDS

020703v2

Authorization To Release Information

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