Authorization To Release Protected Health Information
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1AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
CGHC Claims and Correspondence
PO Box 1630
This form is to be filled out by a member if there is a request to release the member’s health
Brookfield, WI 53008-1630
information to another person or company. Please include as much information as you can.
877-514-2442
I: MEMBER INFORMATION
Member Last Name
Member First Name
MI
Member Date of Birth
Member Street Address
City
State
ZIP Code
Daytime Telephone Number (with area code)
Identification Number (See ID Card)
Group Number (If applicable, see ID card)
II: PERSON OR COMPANY WHO WILL RECEIVE THIS INFORMATION
The following people or company(ies) have the right to receive my information. (They must be 18 years of age or older). Please check
each box that applies and enter first and last name.
My Spouse (First and Last Name)
My Parents (If you are over 18 – First and Last Name[s])
My Domestic Partner (First and Last Name)
My Insurance Broker/Agent (Name of Company, First and Last Name)
My Adult Child(ren) (First and Last Name[s])
Other (First and Last Name, Company, and relation to you)
III: PURPOSE OR NEED FOR DISCLOSURE (Check applicable categories.)
Transferring or Continued Medical Care (Customary to release last two (2) years of information. Release may occur electronically.)
Personal Use Insurance Eligibility/Bene t Disability Determination Legal Investigation
Upcoming Appointment Date: ___________________ Other (Please specify): ________________________________
IV: HEALTH INFORMATION TO BE RELEASED
All my information. This can include health, a diagnosis (name of illness/condition), claims, doctors and other healthcare providers and
nancial information (e.g., billing and banking). This doesn’t include sensitive information (*see below) unless it is approved below.
O ce Visits: Primary Care Speciality (Specify): ________________________ Procedures
Immunization Records Lab Reports X-ray Reports X-ray Films
Billing Records
Speci c information related to: __________________
For the following date(s) or timeframe: From _______/_______/_______ (MM/DD/YYYY) To _______/_______/_______
*Federal and state laws require special permission to release certain information. Please check if these records should be released:
Mental Health Alcohol and/or Drug Abuse HIV/AIDS Test Results Developmental Disabilities
V: EXPIRATION
This authorization will expire on _______/_______/_______ (MM/DD/YYYY). If I do not indicate a date, this Authorization will expire
one (1) year from the date of my signature below. A photocopy of this authorization is as valid as the original.
VI: SIGNATURE
I have read the contents of this form. I understand, agree, and allow Common Ground Healthcare Cooperative (CGHC) to the use and release of
my information as I have stated above. I also understand that signing this form is of my own free will. I understand that CGHC does not require
that I sign this form in order for me to receive treatment or payment, or for enrollment or being eligible for benefits.
I have the right to withdraw this approval at any time by giving written notice of my withdrawal to CGHC. I understand that my withdrawing
this approval will not a ect any action taken before I do so. I also understand that information that’s released may be given out by the person or
group who receives it. If this happens, it may no longer be protected under the HIPAA Privacy Rule. I am entitled to a copy of this form.
Signature: ___________________________________________________ Date: _________________________
If this Authorization is signed by a representative on behalf of the patient, complete the following:
Representative’s Name: _____________________________________ Relationship to Member: ____________________
CGHC.FO.1005-2016
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