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

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.

Include your Social Security/Member Identification Number

List in the “Recipient” section the name of the person or organization to whom you are authorizing

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.

You should only check one of the three boxes listed.

If you select the “Psychotherapy Notes” box, you cannot check any other box

If someone routinely assists you with your health care, for example, husband, wife, son or

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

issue such as an appeal, and initial any/all applicable areas in the *Notes section.

A “Purpose of Release” must also be noted.

An “Expiration” must be listed. You can allow the authorization to remain in effect until you

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

signs the authorization a copy of the legal documents must be submitted with the authorization.

Return the completed authorization form to the following address:

Member Correspondence

P O Box 41890

Philadelphia, PA 19101-1890

Fax Number: 215-241-2042

08162

02192003

Authorization To Release Information Page 3