Hipaa Authorization For Release Of Information printable pdf download

HIPAA Authorization For Release of Information

Section A: I authorize the disclosure of my personal health information to the persons/entities as

described in Section B below. I understand this authorization is voluntary and made to confirm

my directions. I understand that once the information is disclosed, it may be re-disclosed and no

longer protected by federal privacy regulations. I hereby give permission for the disclosure of

my personal health information in the manner described below.

My Name: ____________________________________________________________________

Address: __________________________________________________________________________________________

Telephone: ______________________________ Member Number: __________________________________________

Section B: Personal Health Information to be Disclosed: I authorize the disclosure of the following personal health information:

All medical information relevant to the request for health care coverage, which is the subject of my request for external

review.

Your request will be deemed to include information related to sexually transmitted diseases, such as HIV or AIDS, alcohol or drug use

treatment, or mental health/psychology/psychiatry that may be within your above request, unless you specifically state your objection

here:

Person/Entity Authorized to Disclose: I authorize the person(s) and/or entity(ies) described below to disclose the personal health

information described above:

All Providers with medical records relevant to my request for external review (“Providers”).

Person/Entity Authorized to Receive and Use: I authorize my providers to disclose the non-public personal health information

described above to the entity described below:

The Independent Review Organization (IRO) assigned by the Insurance commissioner of the State of Hawaii to conduct my

external review.

Purpose of the Disclosure: The disclosure is being made for the following reason:

To conduct an external review of an adverse determination made by Cigna, pursuant to my request.

Right to Revoke: I may revoke this authorization in writing at any time. I understand my revocation will not affect any disclosures

that were made by my providers before receipt of my written revocation. If I do not revoke it, this authorization will expire upon

completion of the external review. To revoke this authorization, I must write to the Insurance Commissioner, Department of

Commerce and Consumer Affairs, State of Hawaii, 335 Merchant St., Honolulu, HI 96813.

Signature:

I, ________________________, have had full opportunity to read and consider the contents of this authorization, and I confirm that

the contents are consistent with my direction. I understand that Cigna and my providers will not condition treatment, payment,

enrollment or eligibility for benefits on whether I sign this authorization, but that I must provide this authorization to be eligible for

IRO external review by the insurance commissioner. I further understand that, by signing this form, I am confirming my authorization

that the providers identified above may disclose to the IRO assigned to conduct my external review the nonpublic personal health

information described in this form.

Signature: ________________________________________ Date: ___________________________________________

** ALL DATA FIELDS ABOVE MUST BE COMPLETED FOR A VALID AUTHORIZATION **

If a personal representative on behalf of the individual signs this authorization, complete the following and attach a copy

of legal authority, if applicable, (e.g., medical power of attorney, legal guardianship, etc.):

Personal Representative’s Name: _______________________________________________________________________

Relationship to Individual: ____________________________________________________________________________

"Cigna" is registered service mark and the "Tree of Life" logo is a service mark of Cigna Intellectual Property, Inc., licensed for use by Cigna

Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries, including Connecticut

General Life Insurance Company, and not by Cigna Corporation.

Hipaa Authorization For Release Of Information