Authorization For A One-Time Written Release Of Personal Health Information - Cvs Caremark Form

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Authorization for a one-time written release of personal health information
Requesting the records of the following Plan Participant:
Last Name: ____________________________________________________________________________
First Name: _______________________________________________ Middle Initial: __________
Previous Last Name (if applicable): ____________________________
Address: __________________________________________________________________________
City: ____________________________________ State: _______ Zip Code: ______________
Date of Birth: _________________(mm/dd/yyyy) Phone Number: (________) ___________-_______________
CVS/caremark Plan Participant’s Primary Cardholder Identification Number(s):________________________
Name of Requestor (if different than above): _________________________________________
Relationship to Plan Participant:
[ ] Self
[ ] Legal guardian (Attach legal documentation)
[ ] Parent
[ ] Other: ________________________________________________
(Attach legal documentation)
I hereby authorize CVS/caremark to release the following information for the above Plan Participant:
[ ] Statement of Cost (financial report) from _____________(mm/dd/yyyy) to _____________(mm/dd/yyyy)
[ ] Detailed Prescription History from ______________ (mm/dd/yyyy) to _____________(mm/dd/yyyy)
[ ] Other health information (please specify): _____________________________________________
from____________(mm/dd/yyyy) to ______________(mm/dd/yyyy)
This information should be released to: [ ] Check if same as address above.
Name:
________________________________________
Organization/Entity:
________________________________________
Address:
________________________________________
City/State/Zip:
________________________________________
The purpose of this authorization request is:
[ ] At request of plan participant,
[ ] Required or requested by the recipient for purposes of __________________________________
[ ] Other: _____________________________________________________
This Authorization will expire 90 days from the date of this authorization.
I understand that I have the right to revoke this Authorization at any time. This revocation will not affect any uses
and/or disclosures already made based on this authorization before the revocation is received by CVS/caremark. The
revocation must be in writing and mailed to the address below. I understand that CVS/caremark may not condition
any treatment, payment, enrollment or my eligibility for benefits on my signing this Authorization. I understand that the
information used and/or disclosed pursuant to this authorization may be redisclosed by the recipient and may no
longer be protected by the federal privacy law.
I certify that the foregoing information is true and correct.
Signature: ________________________________________________ Date: _________________
Print Name: _____________________________________________________________________
If signed by someone other than the above-named plan participant, please describe your legal authority to act on
behalf of the plan participant, and, if applicable:__________________________________________________
(Attach supporting documentation)
Witness Signature: ____________________________________________________________
Witness Name: __________________________________________ Date: ________________
Please Return Form To:
CVS/caremark
Attn: Research Department
PO Box 7074
Lee’s Summit, MO 64064-7074

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