Authorization To Release Protected Health Information Form
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1Advantica Administrative Services, Inc.
Authorization to Release
Protected Health Information
A. Individual whose information is to be released:
Name: ___________________________________________________________
Date of Birth: __________________
Phone: ____________________________
Subscriber Name (if different): _________________________________
I, or my authorized representative, request and authorize Advantica Administrative Services, Inc. (Advantica) to
release my personal and health information as described in this authorization.
B. Type of information Advantica may release:
Claims information (including amount billed, procedures, claims payment or denial, etc) from dates: ______ to _____
Premium information (information on premium payments, billing cycles, bank drafts etc.) from dates ______ to _____
Information related to services from _______________________________
for dates: ______ to _____
(provider name)
All of my information (personal, health, demographic, claims, billing, medical records, etc.) for dates: ______ to _____
Other: _______________________________________________________________________________________
_____________________________________________________________________________________________
C. Who may receive your information?
Individual/Entity Name: _____________________________________________ Phone: _________________________
Please indicate how you would like the information sent:
Verbally
Mail
Fax
Secure Email
Street Address: ____________________________________________________________________________________
City: ___________________________
State: ______
Zip: _________
Fax: ____________________________
Email: ___________________________________________________________________________________________
I understand that once this information is disclosed, it may no longer be protected by law, and the recipients may possibly
re-disclose the information to others without my knowledge or consent.
D. Purpose of Authorization:
At my request
Other (explain) ________________________________________________________________________________
E. When will this Authorization Expire? (check one)
Note: If I fail to list an expiration date or event below, this authorization will expire one year from the date signed.
Upon termination of my coverage
On the following date ____________________
On the following event ______________________________
I understand that I have the right to revoke this authorization at any time and that my revocation must be in writing. I
understand the revocation will not be effective for information that Advantica releases between the time that this
Authorization is signed and when the revocation is received.
F. Signature Required:
Signature
Date
If a personal representative is signing this authorization for the individual, please complete the following information and
provide proof of authority.
Name of Personal Representative
Relationship
I UNDERSTAND I MAY REFUSE TO SIGN THIS AUTHORIZATION
Advantica Administrative Services, Inc. does not condition treatment, payment, enrollment or eligibility for benefits on whether an
individual signs this authorization
Returned Completed Form to:
Advantica Administrative Services, Inc.
Attn: Customer Service
PO Box 8510
St. Louis, MO 63126
Fax: (314) 849-4830 or (800) 501-8432
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Parent category: Medical