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).
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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