Health Republic Nj Hippa Authorization Form printable pdf download

Health Republic Nj Hippa Authorization Form

Authorization to Disclose Protected Health Information (PHI)

I hereby give consent to Health Republic Insurance of New York to use and disclose my

protected health information (PHI) for the purposes of payment of my claims (as defined by

the Health Insurance Portability and Accountability Act of 1996 (HIPAA)) to the following

person:

Name of person

consent given to:

Relationship to

Member:

Allow Health Republic Insurance of New York to release:



Limited Information

If Limited is checked, please select which information to release:



Information about eligibility



Information about claims submitted to Health Republic Insurance of New York



Information about benefits and services



Information about premium payments



Other (please specify): ___________________________________________

_________________________________________________________________



Any Information



ALL health-care related Information

This consent will terminate ON: Specify date or indicate no termination*

date________________ (mm/dd/yyyy)

If no termination date indicated, you must notify us to make any changes and/or discontinue

the release of information.

I authorize Health Republic Insurance of New York to disclose my personal health information

listed to the person named above. I understand that my personal health information may be

re-disclosed by the person listed above and may no longer be protected by law. I also

understand that at any time, I have the right to revoke this consent provided that I do so in

writing to Health Republic Insurance of New York.

_________________________________________ ______________________

Signature

Date (mm/dd/yyyy)

HRINY_RC04_PHI_Release form V1

Health Republic Nj Hippa Authorization Form