Member Authorization To Disclose Health Information Sheet printable pdf download

Member Authorization to Disclose Health Information

(Shaded areas denote required fields):

Member Name: __________________________________________________________

Member ID#: _______________________________

Group ID#: _________________________________

Address: _______________________________________________________________

Telephone #: __(____)______-___________

I authorize the use or disclosure of the above-named member’s personal and health information by Humana,

as described below:

Any and all records in the possession of Humana including mental health, HIV and/or substance abuse

records. (Cross out any item you do not authorize to be released)

Records regarding treatment for the following condition or injury _______________________

__________________________________ on or about ______________________________

Records covering the period of time _____________________ to ______________________

Other (Please specify and include dates)____________________________________________

___________________________________________________________________________

This information may be disclosed to, and used by, the following individuals or organizations:

Name: _________________________________________________________________

Address: _______________________________________________________________

Name: _________________________________________________________________

Address: _______________________________________________________________

This information is being disclosed for the following purpose(s):

_____________________________________________________________________________________

I understand that I have the right to revoke this authorization at any time. I understand that in order to

revoke this authorization, I must do so in writing and send my written revocation to Humana’s Privacy Office

to the address below. I understand that the revocation will not apply to information that has already been

released in response to this authorization. I understand that the revocation will not apply to Humana when

the law provides it with the right to contest a claim under my policy. Unless otherwise revoked, this

authorization will expire within thirty (30) months of the signature date.

I understand that I do not have to sign this authorization and that Humana may not condition treatment or

payment on whether I sign this authorization.

I understand that once the information is disclosed pursuant to this authorization, it may be redisclosed by

the recipient and the information may not be protected by federal privacy regulations.

Signature of Member or Legal Representative: __________________________________ Date: _________

If signed by Legal Representative, relationship to Member: _______________________________________

If signed by legal representative, please p ovide rep esentative documen ation as required by s a e

t t

law , i.e. Power of Attorney, Health Care Surrogate, Living Will or Guardianship papers.

Please send this form to: Humana Privacy Office, P.O. Box 1438 Louisville, KY 40202-1438

Humana will follow all Federal and state laws and regulations that are more stringent.

Humana’s Privacy Pledge is to protect customers’ Personal Health Information as if it were our own.

IR-Request for Alternate Comm-10/21/2002

Member Authorization To Disclose Health Information Sheet