TemplatesOwl
Homepage ↦ Fill Out Your Authorization Disclose Health Form
Article Structure

The Authorization to Disclose Health Information form plays a crucial role in the management of personal health records, enabling individuals to take greater control over their medical information. This essential document allows a member to grant permission for their health insurance provider to release designated health information to specified individuals or organizations. Understanding the process of completing the form is vital, as it involves various sections, each with specific requirements. Members need to provide personal information, including their full name, date of birth, and identification number. The form also outlines the health plan that will facilitate the information release. Additionally, it requires the member to identify the recipient who will receive their health information, emphasizing that the designated recipient must be at least 18 years old. The documentation further delineates what types of health information can be disclosed, from psychotherapy notes to a comprehensive view of all medical records. Furthermore, it includes sections where the purpose of the disclosure is to be specified, as well as an expiration date for the authorization. By understanding these components and their implications, members can more effectively navigate their rights to privacy and access in health care, ultimately empowering themselves in their medical journeys.

Authorization Disclose Health Example

Instructions for Completing the Authorization to Disclose Health Information Form

If you have any questions, please feel free to call us at the customer service number on your member identification card.

Please read the following for help completing page one of the form.

1Check this box if you are appealing a denied claim, a denied preauthorization, or your cost share.

Part A: Member Information

This section applies to the member who is asking for the release of his or her information to another person or company.

2Print your first name, middle initial and last name.

3Write your Identification number - You will find this number on your member identification card.

4Write your full street address, city, state, and zip code.

5Write your date of birth.

6Write your daytime phone number (including area code).

Part B: Health Plan that will release your information

7Print the name of your Health Plan that provides your health insurance coverage.

PART C: Recipient - Person or organization that will receive your information

8Write the full name, address, telephone number and relationship to you of the person or company that you want us to give your information to. Please don’t use a general term like “my daughter” or “my son” as it will not be accepted. You need to be specific.

The individual that you designate to receive your information must be 18 years or older. If the individual is an emancipated minor, legal documentation of emancipation must be provided to your Health Plan before your information will be released to the minor.

PART D: Description of the Information to be Released - This section tells us what information

you would like us to release: all or just some.

9For only “psychotherapy notes” check the first box.

10For “all of your information” check the second box.

11For “only limited information” check the box(es) that apply to you.

NOTE: For the release of sensitive information (e.g. HIV/AIDs, drug and alcohol, mental health, genetic testing), you must check the box(es) that apply to you.

1

[Please Print]

 

☐Check this box if you are appealing a denied claim, a denied preauthorization, or your cost share.

Authorization for Disclosure of Health Information

This form is used to release your protected health information as required by federal and state privacy laws. Your authorization allows the Health Plan (your health insurance carrier or HMO) to release your protected health information to a person or organization that you choose. You can revoke this authorization at any time by submitting a request in writing to the Health Plan (contact Member Services for further instructions). Revoking this authorization will not affect any action taken prior to receipt of your written request.

Part A. Member Information: (individual whose information will be released)

Member First Name, Middle Initial and Last Name:

 

Member Identification Number

3

2

 

(see identification

card)

 

 

 

 

 

Member Street Address:

City

State

Zip Code

4

 

 

 

 

 

 

 

 

 

Member Date of Birth:

Daytime Telephone Number (with area code)

 

 

5

 

 

6

 

 

 

 

 

 

Part B. Health Plan: (organization that will release your information)

7

I authorize __________________________________________________________ to release my protected health information as described below.

(Health Plan Name)

Part C. Recipient: (person or organization that will receive your information)

The following individual or company has the right to receive my information (they must be 18 years of age or older).

First Name

8

Last Name

 

 

 

 

 

Company Name (if applicable)

 

 

 

 

 

Address

 

Telephone Number

Relationship to Member in Part A

Part D. Description of the Information to be Released:

I allow the following information to be used or released by my health plan on my behalf (CHECK ONLY ONE BOX):

9☐ Psychotherapy Notes. Federal law requires a separate authorization to use or release psychotherapy notes.

OR

10☐ All My Information. This can include health, diagnosis (name of illness or condition), claims, doctors and other health care providers and

certain financial information (such as premium billing and payment). This does not include sensitive information (see below) unless it is approved below.

OR

11☐ Only Limited Information may be released (check all boxes below that apply to you).

☐ Appeal information

☐ Eligibility and enrollment

☐ Benefits and coverage

☐ Pre-certification and pre-authorization

 

(for treatment approvals)

☐ Premium billing and payment

☐ Referral

☐ Claims and payment

☐ Pharmacy

☐ Diagnosis (name of illness or condition)

☐ Other: _________________________________________________________________

and procedure (treatment)

________________________________________________________________________

I also approve the release of the following types of sensitive information (check all boxes that apply to you):

 

☐ Abortion

☐ Genetic testing

☐ Mental health

 

 

☐ Abuse (sexual/physical/mental)

☐ HIV or AIDS

☐ Sexually transmitted illness

 

✄

☐ Alcohol/substance abuse*

☐ Maternity

☐ Other:___________________________________________________________

* I understand that my alcohol/substance abuse records are protected under Federal and State confidentiality laws

and regulations and

HERE

cannot be disclosed without my written consent unless otherwise provided for in the laws and regulations. I also understand that I may

revoke (or cancel) this approval at any time by providing written notice to my health plan, or as described below in Part F. I understand that

 

I cannot cancel this approval when this form has already been used to disclose information.

 

CUT

 

 

 

 

PLEASE KEEP A COPY OF THIS FORM AND THE INSTRUCTIONS FOR YOUR RECORDS

08161 (7/17)

Instructions for Completing the Authorization to Disclose Health Information Form

If you have any questions, please feel free to call us at the customer service number on your member identification card.

Please read the following for help completing page two of the form.

Part E: Purpose of this approval -

This section tells us the reason you’ve asked for the release of your information.

12Check the first box to let us know to give out this information as shown on this form.

13Check the second box for a specific reason. An example might be to resolve an appeal.

Part F. Expiration date of this approval – This section tells us when you want this authorization to expire.

14Check the first box if you want the authorization to expire when you specifically write to us and revoke it.

15Check the second box if you want the authorization to expire on a specific date or event/condition (for example, when my appeal is resolved) and fill in the date, event or condition.

Part G. Approval

16Sign and print your name and put the date on the form. Your name and signature must match the information in Part A.

17if you are signing this form on behalf of another person, or if you have Power of Attorney for health care, or are a legal guardian/conservator you must do the following:

You must complete the Personal Representative Information section.

You must also provide us with a copy of the legal document showing that you are considered the personal representative of the member and include the document with this form.

Examples of legal documents:

Part E. Purpose of this Approval

12☐ To release information as described on this form

OR

13☐ For the following reason: __________________________________________________________________________________________________

Part F. Expiration Date of this Approval

This authorization will expire (Check ONLY ONE box):

14☐ When I revoke this authorization*

OR

15☐ Upon the following date, event or condition*:_________________________________________________________________________________

*The health plan identified in Section B must be notified in writing of the event/condition to cancel or revoke this authorization.

Part G. Approval: (You OR your Personal Representative must sign and date this form in order for it to be complete.)

I understand that this authorization for disclosure of health information is voluntary and is not a condition of enrollment in this Health Plan, eligibility for benefits, or payment of claims. I also understand that if the person or organization I authorize to receive the information described above is not subject to federal health information privacy laws, they may further release the protected health information and it may no longer be protected by federal privacy laws.

Member Signature: By signing below, I authorize the release of my protected health information as described above.

(Signature of Member)

16

(Print Name)

(Date)

 

 

Personal Representative Information: A Personal Representative is a person who has the legal authority to act on behalf of an individual. A copy of a Power of Attorney or other legal document must be on file at the Health Plan or submitted with this form.

(Printed Name of Personal Representative)

17

(Description of Representative’s Authority)

 

 

 

 

 

 

 

(Date)

(Signature of Personal Representative)

 

(Telephone Number)

 

 

 

 

Return the Completed Form to:

Member Correspondence

P O Box 41890 • Philadelphia, PA 19101-1890

Fax Number: 215-241-2042 or 1-888-457-3013 (Toll Free)

This plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATENCIÓN: Si habla español, cuenta con servicios de asistencia en idiomas disponibles de forma gratuita para usted.

Llame al 1-800-275-2583 (TTY: 711).

注意：如果您讲中文，您可以得到免费的语言协助服务。致电1-800-275-2583。

•General or Durable Power of Attorney. This document gives someone the legal power to act on your behalf and make health care decisions for you.

•Legal Guardianship. This is when the court appoints someone to care for another person.

•Conservatorship. This happens when a judge appoints a responsible person to make decisions for someone who can’t make responsible decisions for him/herself.

•Executor of estate or death certificate. This type of document would be used when the person who is being represented has died.

✄

CUT HERE

CUT HERE ✄

[Please Print]

☐Check this box if you are appealing a denied claim, a denied preauthorization, or your cost share.

Authorization for Disclosure of Health Information

This form is used to release your protected health information as required by federal and state privacy laws. Your authorization allows the Health Plan (your health insurance carrier or HMO) to release your protected health information to a person or organization that you choose. You can revoke this authorization at any time by submitting a request in writing to the Health Plan (contact Member Services for further instructions). Revoking this authorization will not affect any action taken prior to receipt of your written request.

Part A. Member Information: (individual whose information will be released)

Member First Name, Middle Initial and Last Name:

 

Member Identification Number

 

 

 

(see identification

card)

 

 

 

 

 

 

Member Street Address:

City

State

Zip Code

 

 

 

 

 

Member Date of Birth:

Daytime Telephone Number (with area code)

 

 

 

 

 

 

 

Part B. Health Plan: (organization that will release your information)

 

I authorize___________________________________________________________ to release my protected health information as described below.

(Health Plan Name)

 

 

 

 

 

 

 

 

 

Part C. Recipient: (person or organization that will receive your information)

 

The following individual or company has the right to receive my information (they must be 18 years of age or older).

 

 

 

 

 

 

 

 

First Name

 

 

 

Last Name

 

 

 

 

 

 

 

 

Company Name (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

Telephone Number

 

 

 

 

 

 

 

Relationship to Member in Part A

 

 

 

 

 

 

 

 

 

 

Part D. Description of the Information to be Released:

 

I allow the following information to be used or released by my health plan on my behalf (CHECK ONLY ONE BOX):

☐ Psychotherapy Notes. Federal law requires a separate authorization to use or release psychotherapy notes.

 

OR

 

 

 

 

 

 

☐ All My Information. This can include health, diagnosis (name of illness or condition), claims, doctors and other health care providers and

certain financial information (such as

premium billing and payment). This does not include sensitive information (see below) unless it is

approved below.

 

 

 

 

 

 

OR

 

 

 

 

 

 

☐ Only Limited Information may be released (check all boxes below that apply to you).

 

☐ Appeal information

 

☐ Eligibility and enrollment

 

☐ Benefits and coverage

 

☐ Pre-certification and pre-authorization

 

 

 

 

(for treatment approvals)

 

☐ Premium billing and payment

 

☐ Referral

 

☐ Claims and payment

 

☐ Pharmacy

 

☐ Diagnosis (name of illness or condition)

☐ Other: _ _________________________________________________________________

and procedure (treatment)

 

 

________________________________________________________________________

 

 

I also approve the release of the following types of sensitive information (check all boxes that apply to you):

 

☐ Abortion

☐ Genetic testing

☐ Mental health

 

☐ Abuse (sexual/physical/mental)

☐ HIV or AIDS

 

☐ Sexually transmitted illness

 

☐ Alcohol/substance abuse*

☐ Maternity

 

☐ Other:___________________________________________________________

* I understand that my alcohol/substance abuse records are protected under Federal and State confidentiality laws

and regulations and

cannot be disclosed without my written consent unless otherwise provided for in the laws and regulations. I also understand that I may

revoke (or cancel) this approval at any time by providing written notice to my health plan, or as described below in Part F. I understand that

I cannot cancel this approval when this form has already been used to disclose information.

 

 

 

PLEASE KEEP A COPY OF THIS FORM AND THE INSTRUCTIONS FOR YOUR RECORDS

08161 (7/17)

Part E. Purpose of this Approval

☐To release information as described on this form

OR

☐For the following reason: ___________________________________________________________________________________________________

Part F. Expiration Date of this Approval

This authorization will expire (Check ONLY ONE box):

☐When I revoke this authorization*

OR

☐Upon the following date, event or condition*:_________________________________________________________________________________

*The health plan identified in Section B must be notified in writing of the event/condition to cancel or revoke this authorization.

Part G. Approval: (You OR your Personal Representative must sign and date this form in order for it to be complete.)

I understand that this authorization for disclosure of health information is voluntary and is not a condition of enrollment in this Health Plan, eligibility for benefits, or payment of claims. I also understand that if the person or organization I authorize to receive the information described above is not subject to federal health information privacy laws, they may further release the protected health information and it may no longer be protected by federal privacy laws.

Member Signature: By signing below, I authorize the release of my protected health information as described above.

(Signature of Member)

(Print Name)

(Date)

 

 

Personal Representative Information: A Personal Representative is a person who has the legal authority to act on behalf of an individual. A copy of a Power of Attorney or other legal document must be on file at the Health Plan or submitted with this form.

(Printed Name of Personal Representative)

 

(Description of Representative’s Authority)

 

 

 

 

(Date)

(Signature of Personal Representative)

 

(Telephone Number)

 

 

 

 

Return the Completed Form to:

Member Correspondence

P O Box 41890 • Philadelphia, PA 19101-1890

Fax Number: 215-241-2042 or 1-888-457-3013 (Toll Free)

This plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATENCIÓN: Si habla español, cuenta con servicios de asistencia en idiomas disponibles de forma gratuita para usted.

Llame al 1-800-275-2583 (TTY: 711).

注意：如果您讲中文，您可以得到免费的语言协助服务。致电1-800-275-2583。

Language Assistance Services

Spanish: ATENCIÓN: Si habla español, cuenta con servicios de asistencia en idiomas disponibles

de forma gratuita para usted. Llame al número telefónico de Servicio al Cliente que figura en el reverso de su tarjeta de identificación.

Chinese: 注意：如果您讲中文，您可以得到免费的语言 协助服务。请致电您ID卡背面的客户服务电话号码.

Korean: 안내사항: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 귀하의 ID 카드 뒷면에 있는 고객 서비스 번호로 전화해 주십시오.

Portuguese: ATENÇÃO: se você fala português, encontram-se disponíveis serviços gratuitos de assistência ao idioma. Ligue para telefone do Atendimento ao Cliente que está no verso do seu cartão de identificação.

Gujarati: ચનાૂ: જો તમે જરાતીુ બોલતા હો, તો િન: ુક ભાષા સહાય સેવાઓ તમારા માટ ઉપલ ધ છે. પયાૃ તમારા આઇડ કાડની પાછળ ાહક સેવા નંબર પર કોલ કરો.

Vietnamese: LƯU Ý: Nếu bạn nói tiếng Việt, chúng tôi sẽ cung cấp dịch vụ hỗ trợ ngôn ngữ miễn phí cho bạn. Hãy gọi số Dịch Vụ Chăm Sóc Khách Hàng ở mặt sau thẻ ID của bạn.

Russian: ВНИМАНИЕ: Если вы говорите по-русски, то можете бесплатно воспользоваться услугами перевода. Позвоните в службу поддержки клиентов по номеру телефона, указанном на обратной стороне вашей идентификационной карты.

Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer Obsługi klienta znajdujący się na odwrocie Twojego identyfikatora.

Italian: ATTENZIONE: Se lei parla italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiami il numero dell’Assistenza clienti che troverà sul retro della sua tessera identificativa.

Arabic:

ةيوغللا ةدعاسملا تامدخ نإف ،ةيبرعلا ةغللا ثدحتت تنك اذإ :ةظوحلم دوجوملا "ءلامعلا ةمدخ" مقرب لاصتلاا ءاجرلا .ناجملاب كل ةحاتم

.كتيوھ ةقاطب رھظ ىلع

French Creole: ATANSYON : Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Tanpri rele nimewo Sèvis Kliyantèl ki sou do kat idantifikasyon ou a.

Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, magagamit mo ang mga serbisyo na tulong sa wika nang walang bayad. Mangyaring tawagan ang numero ng Customer Service na nasa likod ng iyong ID card.

French: ATTENTION: Si vous parlez français, des services d'aide linguistique-vous sont proposés gratuitement. Veuillez composer le numéro du service clientèle indiqué au dos de votre carte d'identité Médicale.

Pennsylvania Dutch: BASS UFF: Wann du Pennsylvania Deitsch schwetzscht, kannscht du Hilf griege in dei eegni Schprooch unni as es dich ennich eppes koschte zellt. Ruf die Number uff die hinnerscht Seit vun dei ID Card uff fer schwetze mit ebber as dich helfe kann.

Hindi: यान द: यिद आप िहंदी बोलतेह तो आपके िलए मुत म भाषा सहायता सेवाएंउपल ध ह। कृपया अपने आईडी काडर्के पीछेिदए ग्राहक सेवा नंबर पर कॉल कर।

German: ACHTUNG: Wenn Sie Deutsch sprechen, können Sie kostenlos sprachliche Unterstützung anfordern. Bitte rufen Sie unsere Kundendienstnummer auf der Rückseite Ihrer Identifikationskarte an.

Japanese: 備考：母国語が日本語の方は、言語アシス タンスサービス（無料）をご利用いただけます。

ご自分のIDカードの裏面に記載されている

カスタマーサービスの番号へお電話ください。

Persian (Farsi):

تروص هب همجرت تامدخ ،دينک یم تبحص یسراف رگا :هجوت نايرتشم تامدخ هرامش اب ًافطل .دشاب یم مھارف امش یارب ناگيار

.ديريگب سامت تسا هدش جرد امش یياسانش تراک تشپ رد هک

Y0041_HM_17_47643 Accepted 10/14/2016

Taglines as of 10/14/2016

Navajo: D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh. T’11 sh--d7 h0d77lnih koj8’!k1’an7daalwo’j8 47 binumber naaltsoos nit[‘izgo nantin7g77 bine’d66’ bik11’.

Urdu:

ےئل ےک پآ وت ،ںيہ ےتلوب نابز ودرا پآ رگا :ےہراکرد ہجوت ڈراک یتخانش ےک پآ ۔ںيہ بايتسد تامدخ نواعم نابز ںيم تفم لاک مرک ےئارب رپ ربمن تامدخ فراص ےئگےيئد ےھچيپ ےک

.ںيرک

Discrimination is Against the Law

This Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

This Plan provides:

Free aids and services to people with disabilities to communicate effectively with us, such as: qualified sign language interpreters, and written information in other formats (large print, audio, accessible electronic formats, other formats).

Free language services to people whose primary language is not English, such as: qualified interpreters and information written in other languages.

Mon-Khmer, Cambodian: សូមេម ្តចប់ រមមណ៍៖

្របសិនេបើអកនិយយភ មន-ែខមរ ឬភ

ែខមរ េនះ

ជំនួយែផនកភ នឹងមនផ្តល់ជូនដល់េ

កអនកេ យឥត

គិតៃថ្ល។ សូមទូរសពេទេលខេស សមជិក ែដលមនេន

ែផកខងេ្រកយៃនបណ្ណសមគល់ខ្លនរបស់េ កអនក ។

ួ

If you need these services, contact our Civil Rights Coordinator. If you believe that This Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator. You can file a grievance in the following ways: In person or by mail: ATTN: Civil Rights Coordinator, 1901 Market Street, Philadelphia, PA, 19103; By phone: 1-888-377-3933 (TTY: 711), By fax: 215-761-0245, By email: civilrightscoordinator@1901market.com. If you need help filing a grievance, our Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800- 368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Y0041_HM_17_47643 Accepted 10/14/2016

Taglines as of 10/14/2016
Get Authorization Disclose Health PDF Form

Form Characteristics

Fact Name Description
Purpose of the Form This form is utilized to authorize the release of protected health information as mandated by federal and state privacy laws. It empowers individuals to manage who receives their health information.
Member Information Members must provide their full name, identification number, address, date of birth, and phone number. This information identifies the individual whose health information is being disclosed.
Recipient Restrictions The recipient of the health information must be at least 18 years old unless proper documentation regarding emancipation is submitted. Vague descriptors, like “my child,” are not acceptable.
Information Release Options Members can choose to release all their health information, only certain types, or psychotherapy notes. Special conditions apply for sensitive information like mental health records or substance abuse treatment.
Revocation Rights Members have the right to revoke their authorization at any time through written notice to their health plan. Any actions taken prior to this revocation remain unaffected.
Governing Laws This form operates under various federal statutes, including the Health Insurance Portability and Accountability Act (HIPAA), as well as applicable state privacy laws that may differ depending on the jurisdiction.

Guidelines on Utilizing Authorization Disclose Health

Filling out the Authorization to Disclose Health Information form is crucial for anyone needing to share their medical records with another individual or organization. It's important to ensure accuracy and completeness when providing your information. Follow these steps carefully to facilitate a smooth process.

  1. Review the form carefully and check the box if you are appealing a denied claim, preauthorization, or your cost share.
  2. In Part A, print your first name, middle initial, and last name.
  3. Write your Identification number from your member identification card.
  4. Fill in your full street address, city, state, and zip code.
  5. Provide your date of birth.
  6. Add your daytime phone number, including area code.
  7. In Part B, write the name of your Health Plan that will release your information.
  8. In Part C, provide the full name, address, telephone number, and relationship of the person or organization receiving your information. Make sure you are specific and avoid using general terms.
  9. In Part D, indicate the type of information you want released by checking the appropriate box. This includes options for psychotherapy notes, all information, or only limited information.
  10. If applicable, check any boxes for sensitive information you wish to release.
  11. In Part E, state the purpose for the approval of information release.
  12. In Part F, specify the expiration date of this approval either by writing your own or checking the box indicating it will expire upon revocation.
  13. Finally, in Part G, sign and print your name along with the date. If you are signing on someone else’s behalf, complete the necessary sections to verify your authority.

Once completed, make sure to keep a copy of the filled form for your records and ensure it is submitted as directed, either by mail or fax. Timeliness and accuracy are key to avoid delays in processing your request.

What You Should Know About This Form

What is the Authorization to Disclose Health Information form?

This form allows you to release your protected health information to a specified individual or organization. It is used as required by federal and state privacy laws, ensuring your medical details are shared only with those you choose.

Who needs to complete this form?

The member requesting the release of their health information must complete the form. This includes providing personal information like your name, identification number, and contact details. If the request is made by a personal representative, additional documentation will be required.

What information do I need to provide in Part A?

In Part A, you need to include your first name, middle initial, last name, identification number, address, date of birth, and daytime phone number. This identifies the individual whose information will be disclosed.

Who can receive my health information?

The designated recipient must be at least 18 years old. You must provide their full name, address, phone number, and their relationship to you. Avoid using general terms like "my daughter" or "my doctor." Specificity is crucial for compliance.

What types of information can I authorize to be released?

You can authorize the release of all or specific types of health information. Options include psychotherapy notes, general medical records, and sensitive information. Always check the appropriate boxes for what you wish to disclose. Ensure you specify if sensitive information, like HIV status or mental health records, is included.

Can I revoke this authorization after signing?

Yes, you can revoke your authorization at any time by submitting a written request to your health plan. However, any actions taken prior to your revocation will remain unchanged. Ensure you follow the proper procedures for revocation as outlined in the form.

What should I include in Part E regarding the purpose of release?

You should check the box indicating whether you are releasing information as described on the form or specify a particular reason for the request, such as resolving an appeal or another specific need.

How do I specify when this authorization will expire?

In Part F, you can choose to have the authorization expire either when you revoke it or upon a specific date, event, or condition. If selecting a specific event, clearly outline it. Make sure to notify the health plan in writing if you plan to revoke the authorization early.

Where do I send the completed form?

The completed Authorization to Disclose Health Information form should be sent to Member Correspondence at P.O. Box 41890, Philadelphia, PA 19101-1890, or you can fax it to 215-241-2042 or 1-888-457-3013. Ensure you keep a copy for your records.

Common mistakes

Filling out the Authorization to Disclose Health Information form is a crucial process for gaining access to medical records. However, common mistakes can delay the process or lead to complications. One typical error is failing to specify the recipient correctly. It’s essential to provide the full name and contact details of the individual or organization receiving the information. Using vague terms, such as "my daughter" or "my son," is not acceptable. Specificity is key, so ensure the person designated is clearly identified.

Another frequent mistake involves incomplete member information. Individuals often neglect to fill in their identification number, which is located on the member identification card. Omitting this detail can result in rejection of the request. Make sure to double-check that all personal details, including full street address, city, state, zip code, and date of birth, are provided accurately. Incomplete or incorrect information can create significant delays in processing.

People also often misunderstand the type of information they are authorized to release. Many fail to recognize the importance of selecting the appropriate boxes in Part D, which either authorize the release of all information or specific details only. If sensitive information like psychotherapy notes or mental health records is involved, it is crucial to check the right boxes to comply with legal requirements. Taking the time to clarify these sections helps avoid future issues.

In addition, individuals sometimes neglect to include a purpose for the authorization. Part E requires a specific reason for the request. Simply checking the first box without elaboration may not suffice. Providing a clear reason, such as "to resolve an appeal," can offer clarity and expedite the process.

Expiration dates can also be overlooked. Failing to check a box in Part F about expiration may lead to doubts regarding the authorization’s validity. Be sure to understand that the authorization will remain in effect until intentionally revoked or until a specified date or event occurs, so make time to fill this section out correctly.

Another error is the lack of signature or date in Part G. Without your signature or date, the authorization form is incomplete and cannot be processed. Verify that your signature matches the name printed earlier in Part A to prevent any inconsistencies.

Lastly, it’s critical to provide documentation if signing on behalf of someone else. Mistakes happen when personal representatives or legal guardians fail to attach necessary legal documents, such as a Power of Attorney. If you’re acting for someone else, ensure that this information is explicitly included to confirm your authority to act on their behalf.

By being aware of these common mistakes and addressing them before submitting the Authorization to Disclose Health Information form, individuals can ensure a smoother process and avoid unnecessary delays.

Documents used along the form

Several documents and forms are commonly used alongside the Authorization to Disclose Health Information Form. Each serves a specific purpose in healthcare administration, particularly in managing patient information and consent. Understanding these documents can help streamline the process while ensuring compliance with legal requirements.

  • General or Durable Power of Attorney: This document grants someone the authority to make decisions on behalf of another person, especially regarding healthcare. When the individual cannot act for themselves, this becomes crucial for medical decision-making.
  • Legal Guardianship: An appointed guardian is designated by the court to make decisions on behalf of a person who is incapable of doing so. This is often relevant for minors or individuals with disabilities, ensuring their well-being and care needs are met.
  • Conservatorship: Similar to guardianship, a conservatorship is established by a judge, allowing a designated person to make financial and personal decisions for someone unable to manage their own affairs. This often involves significantly disabled individuals.
  • Executor of Estate: This document is essential after a person's death, allowing the designated executor to manage the deceased's estate. This includes the distribution of assets and handling of liabilities according to the deceased's will.
  • Death Certificate: A legal document that officially confirms the death of an individual. It is often required in various processes, including settling the estate and claiming insurance benefits.

Being aware of these associated forms and their functions can significantly enhance the handling of health information and the decision-making processes tied to healthcare and legal representation. Proper use of these documents helps safeguard personal information while ensuring that wishes are respected during medical and legal proceedings.

Similar forms

  • General Power of Attorney: This document grants another person the authority to make decisions on behalf of an individual, including health-related decisions.
  • Durable Power of Attorney: Similar to a general power of attorney, this document remains in effect even if the individual becomes incapacitated.
  • Health Care Proxy: This document allows a person to appoint someone to make health care decisions when they are unable to do so themselves.
  • HIPAA Release Form: This form specifically authorizes health care providers to share an individual's medical records with designated third parties.
  • Medical Release Form: This document permits the release of specific medical records to a defined recipient for a stated purpose.
  • Consent to Treatment: A form signed by patients permitting medical professionals to administer treatment, which often includes sharing information with other providers.
  • Patient Authorization Form: This document covers various aspects of patient confidentiality and allows for the sharing of health information under specific circumstances.
  • Substance Abuse Disclosure Form: Specifically used to release records regarding substance abuse treatment, it requires explicit consent due to the sensitive nature of the information.
  • Release of Information for Research: This form permits the use of health information for research purposes, ensuring patient confidentiality is maintained.
  • Death Certificate Authorization: This document authorizes a person to obtain copies of a deceased individual's medical records or other related information.

Dos and Don'ts

  • Do: Clearly print your full legal name in the Member Information section.
  • Don't: Use vague terms like “my son” or “my daughter” when specifying the recipient of your health information.
  • Do: Ensure that the individual receiving the information is at least 18 years old.
  • Don't: Forget to include your Identification number, which can be found on your member ID card.
  • Do: Check only one box regarding the information you want released.
  • Don't: Leave any required sections blank; this may delay the processing of your request.

Misconceptions

  • Misconception 1: The form can be completed without specific information.

    • This is not true. You must provide accurate and complete details, including names, addresses, and identification numbers.

  • Misconception 2: Anyone can receive the health information.

    • Only individuals who are 18 years or older may receive your information, unless they are emancipated minors with proper documentation.

  • Misconception 3: The authorization to disclose can’t be revoked.

    • You can revoke your authorization at any time by submitting a written request to your health plan.

  • Misconception 4: All health information is automatically released.

    • You need to specify what information you want released. Options include "all information" or "limited information." Be clear about your preferences.

  • Misconception 5: The information will never expire.

    • You can set an expiration date for the authorization. It can be after a specific date or event, or you can choose to revoke it anytime.

  • Misconception 6: The form is the same for all health plans.

    • Each health plan may have slight variations in their forms or requirements. Check with your specific health plan for any updates.

  • Misconception 7: Only general information can be disclosed, like "my daughter."

    • Names must be specific. Using general terms like “my daughter” will not be accepted. Always include full names and relationships.

  • Misconception 8: The form is only necessary for financial transactions.

    • The form is vital for disclosing any protected health information, not just for financial matters. It is about your medical information as well.

  • Misconception 9: Once signed, the authorization is permanent.

    • Your authorization can be canceled or modified at your request. Just make sure it is done in writing to your health plan.

Key takeaways

1. Understand the Purpose: The Authorization to Disclose Health Information form allows you to share your protected health information with a person or organization of your choice. It is important to know why you need to complete this form.

2. Fill Out Member Information Accurately: Ensure that all member details are correct. This includes your full name, identification number, address, date of birth, and phone number. Mistakes in this section can lead to delays.

3. Specify the Recipient: Clearly state who will receive your health information. This includes providing their full name, address, and relationship to you. Avoid general terms; specific names are required for approval.

4. Know Your Rights: You can revoke your authorization at any time by submitting a written request. Understand that revoking the authorization will not affect any action taken before your request was received.

Browse Other Templates

Pa License Plate Peeling - Irregularities in how the form is filled out could stall processing, so careful attention is recommended.

Cdph 612 - Privacy and confidentiality are maintained through the guidelines set for social security number collection.