Authorization to Release Information
The enclosed Authorization form is required in order to allow your health plan to release protected
health information to another person or organization. Please review and complete the form. A
number of important points are highlighted here, for more detailed instructions please refer to the
instructions on the back of the Authorization Form. If you have any questions please contact the
member services department number listed on the back of your member identification card.
Each section of the form must be completed; missing information will result in delays
in processing the authorization.
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Include your Social Security/Member Identification Number
List in the “Recipient” section the name of the person or organization to whom you are authorizing
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your health plan to release information. Be sure to include the recipient’s contact information such
as telephone number, fax number or address.
Review the “Description of the Information to be Released” section before completing.
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You should only check one of the three boxes listed.
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If you select the “Psychotherapy Notes” box, you cannot check any other box
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If someone routinely assists you with your health care, for example, husband, wife, son or
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daughter, you may want to give that person access to all your information. To do this check
the second box in this section and initial any/all applicable areas in the *Notes section.
Check the “Specific Information” box if an individual is assisting you in resolving a particular
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issue such as an appeal, and initial any/all applicable areas in the *Notes section.
A “Purpose of Release” must also be noted.
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An “Expiration” must be listed. You can allow the authorization to remain in effect until you
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revoke it in writing. You may also indicate that the authorization will expire on a specific date or at
the conclusion of an event, such as an appeal.
You or your personal representative must sign the authorization. If a personal representative
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signs the authorization a copy of the legal documents must be submitted with the authorization.
Return the completed authorization form to the following address:
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Member Correspondence
P O Box 41890
Philadelphia, PA 19101-1890
Fax Number: 215-241-2042
08162
02192003