Consent For Release Of Personal & Health Information printable pdf download

Consent for Release of Personal

& Health Information

Member Information: (Individual whose information will be released)

Name: ______________________________________________________________ Date of Birth: ___________________

(First, Middle, Last)

(Month, Day, Year)

Address: ___________________________________________________________________________________________

City

State

Zip Code

Telephone Number:

_____________________________________________________________________

(including area code)

Group Plan #: ___________________________________ Member ID #: ______________________________________

I authorize the use or disclosure of personal and health* information by Humana, as described below:

Any and all personal and health information Humana maintains (including mental health, HIV and/or substance abuse

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

Personal and health information regarding the treatment for the following condition or injury:______________________

_________________________________________________ on or about____________________________________

Personal and health information covering the period of time_______________________ to ______________________

Other (Please specify and include dates):_______________________________________________________________

______________________________________________________________________________________________

Note: This consent form allows personal and health information to be shared via a telephone call with the person being

authorized. It does not apply to the information stored on our web site.

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

Name:____________________________________________________________ Relationship: _______________________

Address:____________________________________________________________________________________________

City: ____________________________________________ State: __________________ Zip Code: ___________________

Name:____________________________________________________________ Relationship: _______________________

Address:____________________________________________________________________________________________

City: ____________________________________________ State: __________________ Zip Code: ___________________

Name:____________________________________________________________ Relationship: _______________________

Address:____________________________________________________________________________________________

City: ____________________________________________ State: __________________ Zip Code: ___________________

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. 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 in 365 days.

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: ________________________________________________________________ Date: ____________

Signature of Legal Representative

only if member is unable to sign**:_______________________________________________________ Date:____________

If signed by Legal Representative, relationship to Member: _____________________________________________________

must provide representative documentation as required by state law

** If signed by legal representative,

, i.e.

Healthcare Power of Attorney, Health Care Surrogate, Living Will or Guardianship papers.

* Health (this includes Medical, Dental & Pharmacy Information)

07/13/05

Consent For Release Of Personal & Health Information

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