Member Designated Release Of Information Form - Coventry Health printable pdf download

Member Designated Release Of Information Form - Coventry Health

University of Missouri Choice Health Care

myChoice, myOptions and myRetiree Programs

Member Designated Release of Information

Your medical information is confidential. The completion of this form permits Coventry Health

Care, Inc. to provide information to the person(s) you name on the attached member designated

release of information form. This form is designed to protect your privacy by allowing those

person(s) you designate to be able to access your information. For instance, you may have your

spouse, your employer or broker, a family member or a friend assist you with your health care

benefits. Information that may be shared with the person(s) will be that which is directly relevant

to the specific customer service issue for which they may be assisting you. This form does not

permit Coventry Health Care, Inc. to release information to anyone except the individual or

entity you name on the attached form.

Coventry Health Care, Inc. will NOT release information pertaining to HIV/AIDs, alcohol or

substance abuse treatment or mental health treatment (all which by law, may require a special

form for release), even if a specific claim or authorization question from the person named below

is raised. This information will only be released to you or your legal representative (such as

legal guardian or verified Health Care Power of Attorney).

Note: You must name your spouse if you want Coventry Health Care, Inc. to release the

information identified previously to your spouse.

If you have any questions please contact Coventry Health Care Member Services, available 24

hours a day, seven days per week at 1-800-613-7721 (TDD: 1-800-328-4089).

Member Designated Release Of Information Form - Coventry Health