Permission To Use And Disclose Protected Health Information Page 2

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[Document Name: Authorization Form to Use & Disclosure PHI]
[Used for: When an individual or functional area identifies the need to use or disclose an enrollee’s protected health information for
non-treatment, payment, or health care operations activities or activities that require an authorization under the HIPAA regulations]
[Used by: Customer Service/Call Centers, IRG]
6. [United Healthcare Services, Inc.] will not get paid from a third party for using or giving out this
information.
7. This permission is voluntary. I may refuse to sign this. If I refuse to sign, it will not affect my health
benefits.
I know that once health information about me has been given out by [United Healthcare Services, Inc.] to a
third party, the health information may not be protected by federal privacy laws.
_______________________________________
______________________________________________
Print your name
Sign your name
_______________________________________
______________________________________________
Witness: Print your name
Sign your name
(A witness signature is only needed if the enrollee signs with an “X” due to physical limitations, illiteracy,
or other reasons)
__________________________________________________________________________________________
PERSONAL REPRESENTATIVE INFORMATION:
Name ____________________________________________________________________________________
Address__________________________________________________________________________________
City___________________________State ____Zip __________Telephone____________________________
Relationship to member: Spouse
Child
Personal Representative Other________________________
Signature of representative:
X ________________________________________________ Date___________________________________________
Important: Guardians, court appointed representatives or other responsible parties must send a copy of legal
documents proving that they have legal authorization, if we have not already received this information.
_________________________________________________
Date

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