Pebtf Hipaa Form 1 - Authorization To Release Protected Health Information

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PEBTF HIPAA FORM 1(au)
AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
Introduction: As described in the PEBTF’s Notice of Privacy Practices, the PEBTF generally
may not release information or documents containing the individually identifiable health information of a
PEBTF member or dependent to persons not involved with treatment, the payment of health benefits, or
the health care operations of the PEBTF unless the PEBTF member or adult dependent signs an
Authorization for Release of such information. For example, the PEBTF will generally not share
protected health information of a PEBTF member with his or her spouse absent an Authorization.
Such Authorization must identify whom you are authorizing to receive information and describe the
information you intend to be disclosed.
Authorization: By my signature below, I hereby authorize the Pennsylvania Employees Benefit
Trust Fund (the “PEBTF”) to release the information or documentation described below to the person
identified below, for the purpose I have indicated:
1.
Subject of Information (Individual whose Information is to be Disclosed):
Myself
Name______________________________________________
Social Security Number________________________________
My dependent child
Name of child:_________________________________
Child’s Social Security Number___________________
2.
Recipient of Information:
Please release the information or documentation described below to:
Name of Recipient: _________________________________________________
Address: _________________________________________________________
Telephone No.: ___________________________
3.
Documents/Information to be Released (check all that apply)
All benefit claims or appeals
Specific claims (specify date(s) of service, claim number, etc.)
________________________________________________________________
Billing/enrollment information
Other (please specify)
________________________________________________________________
NOTE: Information regarding the following specially-protected health conditions will not be disclosed
unless the box is checked.
HIV/AIDS
Mental Health
Substance Abuse
Psychotherapy Notes
4.
Purpose of Disclosure (explain or indicate “at the request of the individual”):
________________________________________________________________________
________________________________________________________________________
Auth 1(au)
Rev. 9/23/2013

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