Article Structure
The United Healthcare Release of Information form serves as a crucial tool for managing the sharing of sensitive health information. It begins by gathering essential personal details, such as the member's name, date of birth, and identification numbers, ensuring that the records are tied to the correct individual. Being fully voluntary, the form emphasizes that signing it is not a condition for receiving treatment or benefits, with certain exceptions. Members must also appreciate the extent to which their health information may be disclosed, which includes various types of sensitive data, such as mental health records and substance abuse treatment information. This understanding is vital since recipients of this data, if not healthcare providers, may not adhere to the same confidentiality protections. Along with authorization specifics, the form highlights the importance of identifying who will receive this information and for what purposes—like treatment management or benefit administration. The potential re-disclosure of health information by third parties raises significant privacy considerations that all members must recognize. Importantly, the form allows members the right to revoke their authorization at any time, although such revocation will typically not impact actions taken by United Healthcare before receiving notice. Finally, members should be aware that some states impose additional requirements, like obtaining a witness signature or specifying the duration of the authorization, which vary according to local laws. This form thus acts as both a pathway for facilitating healthcare services and a protective measure for individuals’ rights relating to their health information.
United Healthcare Release Of Information Example
Authorization for Release of Information
Member’s Name |
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Date of Birth |
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Member or Subscriber ID# |
Chart # |
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Member’s Street Address |
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City |
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State |
Zip Code |
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I understand that this authorization is voluntary. I understand that my health information may be protected by the Federal Rules for Privacy of Individually Identifiable Health Information (Title 45 of the Code of Federal Regulations, Parts 160 and 164), the Federal Rules for Confidentiality of Alcohol and Drug Abuse Patient Records (Title 42 of the Code of Federal Regulations, Chapter I, Part 2), and/or state laws. I understand that my health information may be subject to
I understand that my health information may contain information created by other persons or entities including health care providers, and may also contain drug and alcohol, mental health, HIV/AIDS, psychotherapy, reproductive and sexually transmitted disease information. I further understand that by signing this document, I am authorizing the release or exchange of this information with the person or organization named below.
I understand that my health plan may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this form, except for certain eligibility or enrollment determinations prior to my enrollment in its health plan, and for health care that is solely for the purpose of creating protected health information for disclosure to a third party.
I understand that I may revoke this authorization at any time by notifying UnitedHealthcare in writing. However, the revocation will not have an effect on any actions UnitedHealthcare took before it received the revocation.
I authorize UnitedHealthcare to receive from or disclose my individually identifiable health information to the following person(s) or organization(s):
Name:
Address:
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Phone Number: ( ) |
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Extension |
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UnitedHealthcare Authorization for Release of Information |
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Description of individually identifiable health information to be received or disclosed (check appropriate type(s) of information):
All |
Treatment Plan(s) |
Claims |
Progress Reports |
Eligibility/Benefits |
Attendance Only |
Information used to make benefit determinations |
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All pertinent information UnitedHealthcare deems appropriate for the purpose checked below 
Other (describe):
The purpose of this authorization is (check all that apply):
To allow the appropriate management of treatment, services, and/or coverage under the member’s benefit plan.
Benefit Management |
Administration of a Worker’s Compensation claim |
Claims Administration/Payment |
Administration of a Disability claim |
Employer Mandated Treatment Referral |
Subpoena or other legal process |
Other (describe): |
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The dates of records to be disclosed:
From |
_______ (MM/DD/YYYY) To |
________ (MM/DD/YYYY) |
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THE MEMBER OR MEMBER’S REPRESENTATIVE MUST COMPLETE THE REST OF THIS FORM: I understand that this authorization will expire:
On |
________ (MM/DD/YYYY) |
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OR |
Once the following event occurs (does not apply to Illinois residents):
(Form must be completed before signing)
Signature of Member/Legal Guardian |
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Signature of Minor Member |
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Date |
or Member’s Representative |
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Print Name of Member/Legal Guardian |
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Relationship to Member |
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Description of |
or Member’s Representative |
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Representative’s Authority |
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(For Illinois residents only) Witness Signature |
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Date of Witness Signature |
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(For California and Georgia residents only) I understand that I may see and copy the information described on this form if I ask for it, and that I may receive a copy of this form after I sign it.
(For California and Georgia residents only) A copy of this form has been requested and received:
_____ Yes _____ No
PLEASE MAINTAIN A COPY OF THIS DOCUMENT FOR YOUR RECORDS
UnitedHealthcare Authorization for Release of Information |
Page 3 |
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Please return the completed form to:
UnitedHealthcare
Customer Service Privacy Unit
P O Box 740815
Atlanta, GA
PLEASE NOTE THE FOLLOWING
Arizona: The request must be in writing and signed by the person requesting the medical records. The person requesting the medical records must demonstrate the authority to have access to the records.
California: The patient or the person signing this form has the right to receive a copy of the form. Authorization terminates upon the earlier termination of policy coverage, or 60 days after the termination of treatment.
Georgia: Advises that the individual, or the individual’s authorized representative, is entitled to receive a copy of the authorization form.
Illinois: A witness signature is required. The authorization must specify expiration date as a calendar date (i.e., month/day/year). If no calendar date is specified, the information may be released only on the day the consent form is received. Must include right to inspect and copy information to be disclosed. Must also include consequences of refusal to consent, if any. Records do not include information regarding HIV/AIDS status without an authorization that explicitly and specifically includes the release of such information.
Indiana: Expiration of the authorization may be a date, event or other condition. If no expiration is specified, the authorization is valid for 180 days after the date the request was made.
Iowa: The individual has the right to inspect the disclosed information at any time.
Minnesota: Authorization expires on the earlier of the specific date stated or one year from date signed.
Oregon: Unless revoked earlier, the authorization will expire 180 days from the date of signing or shall remain in effect for the period reasonable needed to complete the request.
Virginia: To be valid, the authorization must state the inclusive dates of the records to be disclosed.
Washington: Authorization expires on the earlier of the specific date stated or 90 days after signed, including authorization to release future health care information, except information to third party health care payors.
Form Characteristics
| Fact Name | Description |
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| Voluntary Authorization | The completion of the United Healthcare Release of Information form is voluntary and cannot be forced upon a member. |
| Expiration of Authorization | The authorization can expire either on a specified date or an event, depending on state laws and member’s choice. |
| Revocation Rights | Members have the right to revoke their authorization at any time, but it will not affect actions taken prior to the revocation. |
| Protected Information | The form states that health information may include sensitive data such as mental health and drug and alcohol treatment records. |
| State-Specific Requirements | Each state may have unique requirements regarding the authorization, such as witness signatures and duration of validity. |
| Right to Copy | Members are entitled to receive a copy of the authorization form after signing it, as mandated by certain states like California and Georgia. |
| Federal Protections | Health information is protected under federal regulations, including 45 CFR Parts 160 and 164, ensuring privacy for members. |
| Eligibility for Benefits | Signing this form cannot condition treatment, payment, or eligibility for benefits, except under specific circumstances. |
| Disclosure Purpose | Members must specify the purpose of the authorization, whether it is for treatment management, legal processes, or other reasons. |
Guidelines on Utilizing United Healthcare Release Of Information
Once you have gathered your information, you can proceed to fill out the United Healthcare Release of Information form. It is essential to ensure accuracy in all fields to prevent delays in processing your request.
- Fill out Member Information: Enter your name, date of birth, member or subscriber ID number, chart number, and address including city, state, and zip code.
- Understand Authorization: Read the section that explains your voluntary authorization and the confidentiality of your health information.
- Specify Recipients: Provide the name, address, city, state, zip code, and phone number of the person or organization to whom your information will be disclosed.
- Choose Information Type: Check the appropriate boxes for the type(s) of individually identifiable health information you wish to disclose.
- State Purpose: Indicate the purpose of this authorization by checking all applicable boxes.
- Set Timeframe: Specify the dates from which records will be disclosed by filling in the start date and end date.
- Expiration Date: Indicate when you want the authorization to expire by entering a date or describing an event.
- Signature: Sign the form as the member, legal guardian, or authorized representative and date it.
- Print Name: Clearly print the name of the member, legal guardian, or authorized representative below the signature line.
- Complete Witness Section: If you live in Illinois, ensure a witness signs and dates the form.
- Return Form: Send the completed form to UnitedHealthcare at the provided address.
After submitting the form, UnitedHealthcare will process your request. Keep a copy of the completed form for your records to track your authorization and for any future needs. If you have any questions after submitting, you can reach out to UnitedHealthcare for assistance.
What You Should Know About This Form
What is the United Healthcare Release Of Information form?
This form allows members to authorize the release of their health information to specific individuals or organizations. It ensures that members can manage their healthcare by allowing relevant parties access to necessary medical records.
Who can I authorize to receive my information using this form?
You can authorize any person or organization of your choice. Just include their name, address, and phone number on the form. It’s important to select a trusted individual or entity, as they will have access to sensitive health information.
What types of information can be released?
The form allows the release of various types of health information. You can select from options like treatment plans, claims, eligibility details, or any other pertinent information that UnitedHealthcare finds necessary for the outlined purpose.
What is the expiration date of the authorization?
You can specify an expiration date for your authorization on the form. If no date is provided, regulations will dictate the duration based on state-specific laws. In some cases, the authorization may last for a predetermined number of days, such as 90 days or even up to a year.
Can I revoke the authorization after I have signed the form?
Yes, you have the right to revoke your authorization at any time. To do so, simply notify UnitedHealthcare in writing. However, this will only apply going forward and will not affect any disclosures made before the revocation was received.
What should I do if I live in a specific state that has additional requirements?
Each state has its own provisions that may require additional information on the authorization form. For instance, in Illinois, a witness signature is mandatory. Always make sure to check your state's specific regulations to ensure compliance and validity of your authorization.
Can I obtain a copy of this form?
Yes, you are entitled to receive a copy of the Release Of Information form after signing it. This ensures that you have a record of the authorization for your personal files.
Common mistakes
Filling out the United Healthcare Release of Information form can be a straightforward task, but many people make common errors that can lead to delays or complications. One frequent mistake is failing to provide complete and accurate personal information. This includes details like the member’s name, date of birth, and member ID number. If any of this information is incorrect or missing, it can prevent the release from being processed.
Another common issue occurs with the description of the information to be disclosed. Often, individuals check only some boxes without fully understanding what each entails. This can result in a lack of necessary information being shared, which may affect medical treatment or claims processing. Ensuring that all relevant options are checked can significantly improve the outcome.
People sometimes neglect to specify the purpose of the authorization. Without indicating why the information is needed, such as for treatment management or claims administration, the release may not be accepted. The purpose should be clearly marked in the designated section to avoid confusion.
Additionally, the dates of records to be disclosed are frequently overlooked. It is vital to include a clear start and end date for the records requested. Failing to do so, or leaving this section incomplete, can result in a refusal to process the request. Ensure the dates are written in the correct format to avoid any mistakes.
Another mistake involves the signature section. Some individuals forget to sign the form altogether, while others may not complete the necessary details about their relationship to the member. This part is critical; a missing signature can render the entire authorization invalid, leading to further delays.
In certain states, there are specific provisions that must be followed, and not adhering to these can create issues. For instance, Illinois requires a witness signature, and in California, patients must be informed about their rights regarding the form. Ignoring these state-specific requirements can lead to complications in getting the authorization accepted.
Moreover, individuals often do not make a copy of the completed form for their records. Keeping a record is crucial as it not only serves as a reference but also is important if any disputes arise concerning what was authorized for release.
Finally, many people overlook the option to revoke the authorization. Understanding that this can be done at any time, without affecting prior actions taken, is essential. Ensuring that the revocation process is clear in their mind helps maintain control over personal health information.
Documents used along the form
The United Healthcare Release of Information form is a crucial document in managing your healthcare-related information. However, it often works alongside various other forms and documents necessary for facilitating different aspects of healthcare, insurance, or legal processes. Below is a list of related documents that are frequently used to ensure seamless information sharing and compliance with privacy regulations.
- Consent to Release Mental Health Records: This form grants specific permission to share mental health information with designated parties. It's essential when individuals seek treatment involving mental health professionals.
- Patient Intake Form: This document collects basic information from new patients, including demographics, medical history, and insurance details. It helps healthcare providers understand the patient’s needs and background.
- Authorization for Payment Assignment: This form allows healthcare providers to directly bill insurance companies and receive payment for services rendered. It streamlines the claims process and ensures timely reimbursement.
- Medical Records Request Form: Patients often use this form to request copies of their health records from providers. It ensures that they have access to their information when needed, facilitating ongoing care.
- Notice of Privacy Practices: This document informs patients how their medical information may be used and shared by healthcare providers. It educates them on their rights regarding their personal health information.
- Durable Power of Attorney for Healthcare: This legal document designates someone to make healthcare decisions on a person’s behalf if they are unable to do so. It provides clarity and peace of mind for patients and their families regarding medical care decisions.
Utilizing these documents in conjunction with the United Healthcare Release of Information form can provide comprehensive management of healthcare needs while maintaining the privacy and security of sensitive information. Each form serves a specific purpose and complements the overall process of health information management, ensuring that individuals receive the care they need without unnecessary barriers.
Similar forms
The United Healthcare Release of Information form plays a vital role in handling medical records. There are several other documents that are similar in purpose and function. Here’s a look at five of them:
- HIPAA Authorization Form: This document allows patients to authorize the release of their health information to specific individuals or entities. Like the United Healthcare form, it ensures compliance with privacy laws and details the scope of information being shared.
- Medical Records Release Form: A standard document used by healthcare providers to obtain permission from patients for sharing medical records with other parties. Similar to the United Healthcare form, it identifies the information to be disclosed and the purpose of the disclosure.
- Consent to Treatment Form: Patients often sign this form before receiving medical treatment, allowing healthcare providers to use their medical information for diagnosis and care. It shares the principle of informed consent, just like the United Healthcare Release of Information form, ensuring patients are aware of how their information will be used.
- Power of Attorney for Healthcare: This legal document gives a designated individual the authority to make medical decisions on behalf of a patient if they are unable to do so. It relates to the Release of Information form as both permit the sharing of medical data, ensuring that the designated agent can access necessary information.
- Financial Consent Form: Used in situations where patients authorize the release of medical billing information to third parties, such as insurance companies. It is akin to the United Healthcare form as it outlines what information is shared and the purpose behind it, focusing on the financial aspects of healthcare services.
In summary, these documents ensure transparency in handling personal health information while affording individuals the necessary control over their healthcare data.
Dos and Don'ts
Things to Do When Filling Out the United Healthcare Release of Information Form:
- Provide your full name and date of birth accurately.
- Include your Member or Subscriber ID number and chart number.
- Clearly indicate the purpose of the information release.
- Check all relevant types of health information you wish to disclose.
- Sign and date the form to validate your authorization.
Things Not to Do When Filling Out the United Healthcare Release of Information Form:
- Do not leave any required fields blank.
- Avoid providing vague or unclear information.
- Do not use abbreviations that may confuse the information recipient.
- Do not forget to check your state-specific provisions before submitting.
- Refrain from signing the form if you do not fully understand it.
Misconceptions
When it comes to the United Healthcare Release of Information form, a few misconceptions tend to swirl around, creating confusion. Here are four such misunderstandings and the truth behind them:
- Misconception 1: Signing the form is mandatory to receive healthcare services.
- Misconception 2: Once I sign the form, my information is free for anyone to access permanently.
- Misconception 3: This form only covers basic health information.
- Misconception 4: I cannot revoke my authorization once it is signed.
This is not true. The authorization to release information is voluntary. Your health plan cannot condition your treatment or enrollment on whether you sign this form, except under very specific circumstances that pertain to eligibility or enrollment determinations.
Actually, the authorization has an expiration date which you specify when signing. The form allows you to manage who can access your information and for how long, ensuring your privacy is respected and protected.
This impression is misleading. The form encompasses a wide range of health information, including sensitive topics like mental health records, substance abuse history, and HIV/AIDS status, depending on your specifications. You control what information is shared.
In fact, you can revoke your authorization at any time by informing UnitedHealthcare in writing. However, understand that this revocation will not affect any actions taken prior to the revocation being received.
Key takeaways
When filling out the United Healthcare Release of Information form, consider these key takeaways:
- Voluntary Participation: Signing the form is completely voluntary. You should feel no pressure to authorize the release of your health information.
- Understanding Privacy Protections: Your health information is protected by federal and state privacy laws. Be aware of the implications of sharing your information.
- Re-disclosure Risks: Once your information is shared, the recipient may share it again without your consent, depending on their policies.
- Comprehensive Information: Be ready to provide various types of information, including drug and alcohol records, mental health history, or other sensitive data.
- Revocation Rights: You can revoke this authorization at any time by notifying UnitedHealthcare in writing. However, revocation won’t affect actions taken before they received the request.
- Expiration Dates: Clearly state the expiration date for the authorization. If no date is given, limitations may apply based on state laws. <
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