Form 4361 As - Authorization To Disclose Protected Health Information

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AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
Full Name________________________________________________________
Asuris ID#______________________________ Date of Birth ______________
I authorize Asuris Northwest Health to disclose the following information:
Enrollment, eligibility, and benefit information
Claims, claim status, and claim history*
Medical records and diagnosis*
Premium and billing information
Psychotherapy notes*
Other__________________________
Asuris is authorized to disclose the information identified above to the following person(s) or entity(ies):
Name___________________________________________
Name_________________________________________
Address_________________________________________
Address________________________________________
Phone﴾_____﴿_____________________
Phone﴾_____﴿_____________________
The purpose of this disclosure is:
to assist me with my health plan
Other_____________________________________
This authorization is valid for two years from the date of my signature or until _________________________
_______________________________________(cannot exceed two years from date of signature).
I may cancel this authorization at any time by sending written notice to Asuris, P.O. Box 1271, Portland, OR 97207-1271, MS-C7A,
Portland, OR 97207-1271. Cancellation of this authorization will not affect any actions taken by Asuris before receiving my
cancellation notice.
I understand completing this authorization is not a condition to receive treatment, payment, or eligibility. Asuris is not responsible for
any action taken by an authorized recipient of my protected health information. I am aware that an authorized recipient may redisclose
my information and the privacy protections provided by law may be lost.
►________________________________________________
_____________________________
Signed
Dated
If this authorization is signed by a person acting on behalf of another person, please complete the following and attach
documentation demonstrating your authority to act on behalf of another. (e.g., power of attorney, guardianship, conservatorship, etc.)
________________________________________ ﴾_____﴿_______________
________________________
Name of Personal Representative (please print)
Phone
Relationship
►______________________________________________________________
Signature of Personal Representative
*Note: Information about claims, medical records, diagnosis, and psychotherapy notes may contain sensitive data, including data related to treatment of chemical
Dependency, sexually transmitted disease, HIV/AIDS, mental health, and reproduction or contraception. DO NOT check the boxes authorizing the disclosure of
Claims, medical records, diagnosis, or psychotherapy notes if you do not want information relating to these sensitive conditions released.
Please return completed form to Asuris: P.O. Box 1271 MS-C7A, Portland, OR 97207-1271
FORM 4361 AS (Rev.8/12)

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