Authorization To Release Information (Page 2 of 3) in pdf

[Please print}

Instructions - Authorization to Release Information

This form is used for you or your personal representative to authorize the Health Plan to release your protected health

information to another person or organization at your request.

“Protected health information,” means individually identifiable health information. It is information about you, including your

name, address and medical information and may relate to your past, present or future physical or mental health or condition.

The Health Plan maintains information that may include eligibility, benefits, claims or payment information.

Member Information:

(individual whose information will be released)

Print your complete name, address, date-of-birth and telephone number. Provide your group name and number if available.

Social Security number is optional.

Important: Provide the Member ID Number located on the front of your Health Plan identification card. Be sure to

include any letters in front of the identification number.

Health Plan:

(organization that will release your information)

The Health Plan is your insurance carrier or HMO that maintains information about you. Print the name of your Health Plan

on the line provided.

Recipient:

(person or organization that will receive your information)

The recipient is a person or organization that you choose to receive your protected health information from the Health Plan.

You must provide all of the contact information in order for the information to be released.

Identify the person, family member or organization to receive your information.

Provide the contact information about the person, family member or organization

Description of the Information to be Released:

(what type of information will be released)

You must indicate or describe the information to be released. Check one box that best describes your request. There

are three choices. The first choice is Psychotherapy Notes. The second choice is All Information. The third choice is

Specific Information that you must describe on the line provided.

If this authorization is to release psychotherapy notes, the Health Plan cannot release any other information

unless you complete another Authorization to Release Information form.

Psychotherapy Notes are notes recorded by a mental health professional documenting or analyzing the contents of a

conversation during a private counseling session or a group, joint, or family counseling session. These notes are separated

from the rest of the individual’s medical record. Psychotherapy notes cannot be combined with an authorization to

release any other type of information.

All Information

. If you check this box the Health Plan may release all information related to the provision of a payment for

my health care benefits or services. If someone is directly involved in coordinating your health care or benefits, you may

want them to have access to all of your information.

Specific Information.

By checking this box, you indicate that you want only specific information to be released.

Describe the specific information on the line provided.

Purpose of Release.

You must provide a brief description of the reason you want this information released. The

statement, “At my request” is sufficient.

IMPORTANT: State law requires that you give specific permission to release certain health information. Your initials are

required on each line in order for the Health Plan to release information for HIV/AIDS, Substance/Alcohol Abuse, Genetic

information or Mental/Behavioral Health information.

Expiration:

(when this authorization will end)

Print either an expiration date OR event, but not both. If an expiration event is used, the event must relate to the purpose of

the release of information being authorized.

Approval:

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

Member Signature.

Personal Representative Information.

If you are the personal representative, the

If you are the individual whose

member’s signature is not required. However, you must provide the requested information,

information will be released, you must

signature and date. A copy of the legal authority, such as a Power of Attorney or other court-

sign and date in this section.

initiated document, must be on file with the Health Plan.

08161

RETURN THIS FORM AS INSTRUCTED BY YOUR HEALTH PLAN

020703v2

Authorization To Release Information Page 2

Related Articles

Related forms

Related Categories