Form Hwm-F023 - Authorization Form (Page 2 of 2) in pdf

Form Hwm-F023 - Authorization Form Page 2

PART III: Description of Information

I authorize the Fund to disclose my protected health information (PHI) – including written, electronic, or oral information, to the

person(s) identified in Part I of this form in connection with the following information:

ALL claims information for benefits covered under the Plan for the period authorized in Part I

SPECIFIC claims information (Mark all that apply below)

ALL MEDICAL claims

ALL DENTAL claims

ALL VISION claims

ALL MENTAL claims

ALL PRESCRIPTION claims

Claims in a SPECIFIC PERIOD

Claims by SPECIFIC PROVIDER

(MM/DD/YY)

Provider Name :

Date of Services :

OTHERS:

(Please be specific)

PART IV: Purpose of use or disclosure

The purpose for which the individual named in Part I of this Authorization Form may have access to my PHI is as follows:

(Please mark all that apply.)

For any purpose

Health care claims or appeals

Payment for health care

Coordination of benefits

Eligibility in Fund

Premiums and co-payments

Preauthorization

Subrogation and Reimbursement

Other purpose (explain):

PART V: Acknowledgement and SIGNATURE

I understand that :

•

The Fund will provide a copy of this signed Authorization to me

•

I have the right to refuse to sign this Authorization form

•

I have the right to revoke this form at any time by submitting a Cancellation of Authorization

Form to the Fund

•

Cancellation will take effect as of the cancellation date or event, or once the fund receives a

Cancellation of Authorization Form

•

The person I am authorizing to receive my PHI may not be required to treat this information

as confidential

Your Signature

Print Name

(or Signature of Personal Representative*)

*If you are acting as the Personal Representative of the individual whose PHI is to be disclosed, you must provide proof of your authority to act for that individual.

Form Hwm-F023 - Authorization Form Page 2

Related Articles

Related forms

Related Categories