Tuesday, February 10, 2015


                                              Release of information
                                          AUTHORIZATION FORM

I, ____________________________________hereby authorize _______________________ and its affiliates, its employees and agents (collectively ________________________), to release to _______________________________
[Insert full name of person/organization]

my personal health information maintained by ___________________ (e.g., information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided to me and which identifies my name, address, social security number, Member ID number) except the following information about me:


[DESCRIBE INFORMATION NOT TO BE DISCLOSED, IF ANY] for the purpose of helping me to resolve claims and health benefit coverage issues. I understand that any personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person/organization and may no longer be protected by applicable federal and state privacy laws. This authorization is valid from the date of my/my representative’s signature below and shall expire the earlier of __________________________ [INSERT DATE/EVENT UPON WHICH THIS AUTHORIZATION EXPIRES] or the date my coverage ends with _________________. I understand that I have a right to revoke this authorization by providing written notice to _______________________. However, this authorization may not be revoked if _______________________, it’s employees or agents have taken action on this authorization prior to receiving my written notice. I also understand that I have a right to have a copy of this authorization. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my eligibility for benefits or enrollment or payment for or coverage of services.

Name of Member:
Signature of Member: _______________________________________

 If applicable, Legal Representatives sign below: By signing this form, I represent that I am the legal representative of the Member identified above and will provide written proof (e.g., Power of Attorney, living will, guardianship papers, etc.) that I am legally authorized to act on the Member’s behalf with respect to this authorization form.

Name of Legal Representative: ____________________________________
Signature of Legal Representative: _________________________________
Date: _________________________________

Name of Witness: ________________________________________

Signature of Witness: ____________________________________

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