Permission To Use And Disclose Protected Health Information printable pdf download

Permission To Use And Disclose Protected Health Information

[Document Name: Authorization Form to Use & Disclosure PHI]

[Used for: When an individual or functional area identifies the need to use or disclose an enrollee’s protected health information for

non-treatment, payment, or health care operations activities or activities that require an authorization under the HIPAA regulations]

[Used by: Customer Service/Call Centers, IRG]

Enrollee full name__________________________

Enrollee ID: _____________________

Enrollee address ___________________________________

Group Number:

Enrollee city, state, zip_______________________

PERMISSION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

(AUTHORIZATION)

You must complete both sides of this form. If you have a legal representative, they can complete this

form for you. A fax of this form is the same as the original. When we get your form back, we will mail

you a copy.

I allow [United Healthcare Services, Inc., on behalf of itself and related companies] to use or give out my

medical, claim and benefit records. These records may include personal health information. These records

may have information created by others. These records may have information on specific treatment or services

you have received. These records may also include mental health services but psychotherapy notes may be

given out only with separate permission.

1. Those permitted to get the information:

<For internal (UHG/Ovations/UnitedHealthcare) requests, prefill response>_______________________

2. Type of information [United Healthcare Services, Inc.] may use or give out:

____________________________________________________________________________________

3. The information will be used or given out for:

___________________________________________________________________________________

4. I may end this permission at any time. I must put it in writing. I can call Customer Service for a form. I can

end this except,

a. if [United Healthcare Services, Inc.] has already acted on my permission; or

b. if I gave permission to [United Healthcare Services, Inc.] to review my request for insurance, and other

law provides the insurance company the right to not pay a claim under the policy.

5. This permission expires [on] [upon] _____________[date] or ______________[event] or until [United

Healthcare Services, Inc.] receives my form which ends permission to use or give out my medical

information.

Permission To Use And Disclose Protected Health Information