Consent For Release Of Protected Health Information
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1Consent for Release
Your guide to enrollment
CoverageFirst
PPO
®
Protected Health Information
of
Member information (person whose information will be released):
Your name: _______________________________________________________Date of birth: __________________________
First
Middle
Last
Month
Day
Year
Address: ________________________________________________________________________________________________
Street
City
State
Phone
Member ID: _____________________________________ Group # (if applicable): __________________ZIP code: _________
I understand that this authorization will allow Humana and its affiliates to use or disclose the protected
health* information described below:
❑ Any and all protected health information Humana and its affiliates maintains, including mental health, HIV, or
substance abuse records. Cross out any item you do not authorize for release.
❑ Protected health information about treatment for the following condition or injury:
____________________________________________________________________________________________________
❑ Other. Please specify and include dates: ___________________________________________________________________
Note: It does not apply to information stored on our Website.
This information can be disclosed to, and used by, the following people or organizations:
Name: _________________________________________ Date of birth: ________________ Relationship: _______________
Address: ____________________________________________________________________ E-mail: ____________________
City: _____________________________________ State: _____________ ZIP code: _____________ Phone ______________
Name: _________________________________________ Date of birth: ________________ Relationship: _______________
Address: ____________________________________________________________________ E-mail: ____________________
City: _____________________________________ State: _____________ ZIP code: _____________ Phone ______________
This information is being disclosed to allow the person(s) named above to assist me with my Humana plan.
I understand I have the right to revoke this authorization at any time by sending written revocation to Humana.
I understand the revocation will not apply to information that has been released in response to this authorization.
I understand the revocation will not apply to Humana when the law provides the right for Humana to contest a
claim under my policy. Unless otherwise revoked, this authorization will expire in 24 months.
I understand I do not have to sign this authorization and that Humana cannot base treatment or payment decisions on
whether I sign this authorization. I understand that after the information is disclosed pursuant to this authorization, it can
be redisclosed by the recipient and the information may not be protected by federal privacy regulations.
Member or Legal Representative signature: __________________________________ Date: __________________________
Please note: Legal representatives must attach copies of authorization as required by law. Examples include
healthcare power of attorney, healthcare surrogate, living will, or guardianship papers.
1-888-556-2128. OR
After you complete and sign the form, please fax it to
If you prefer, mail your completed form to: Humana Insurance Company, P.O. Box 14601, Lexington, KY 40512-4601
* Health includes Medical, Dental, Pharmacy and Behavioral Health
Humana will follow the more stringent of all federal and state laws and regulations.
GCA07A0HH 11/09
For Humana Use Only
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