Ca Request And Authorization For Disclosure Of Health Information
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4Request and Authorization for Disclosure of Health Information
PLEASE PRINT or TYPE
EFFECTIVE AS OF ____________________
This is an authorization requesting __________________________________ [Name of Health
Plan-organization that will release your information] to release individual health information
protected by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), or by
state law protecting the privacy of health information. I hereby authorize the use and disclosure
of the individually identifiable health information as described below.
(1)
The request for release of information is being made for the dental plan member
identified below.
__________________
___________________ ____________
___/___/______
Identification Number
Member’s Name
Date of Birth
_____________________________________________________
(___)____-_____
Mailing Address
Telephone Number
(2)
Specific description of information that may be used/disclosed:
□ Claims Information
□ Payment Information
□ Other Information (must provide specific description): _________________________
________________________________________________________________________
(3)
The information will be used/disclosed for the following purpose(s):
□ Obtaining Claims Information or Payment Information for the Resolution of Claim
Processing or Payment Issues
□ Other: ________________________________________________________________
(4)
Persons/organizations authorized to receive the information:
□ Family Members (must list name and relationship): __________________________
___________________ ________________________ __________________________
□ All Group Health Plan Representatives at member’s place of employment (provide
name of member’s employer): ______________________________________________
CA Request and Authorization for Disclosure of Health Information-3/21/14
9/27/16
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Parent category: Medical