Transcription of Authorization for Release of Information - AmeriHealth
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Authorization for Release of Information - AmeriHealth
PLEASE KEEP A COPY OF THIS FORM AND THE INSTRUCTIONS FOR YOUR RECORDS 08161 (9/05) Authorization to Release Information [Please Print] 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. Member Information : (individual whose Information will be released) Name: (First, Middle, Last, Title) Member ID Number: Date of Birth: (Month/Day/Year) Address: (including zip code) Telephone Number: (including area code) Health Plan: (organization that will Release your Information ) I authorize _____ to Release my protected health Information as described below.
Authorization to Release Information [Please Print] 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. ...
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