Form BEN043 "Authorization for the Use and/or Disclosure of Protected Health Information (Phi)" - Alaska

What Is Form BEN043?

This is a legal form that was released by the Alaska Department of Administration - a government authority operating within Alaska. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2021;
  • The latest edition provided by the Alaska Department of Administration;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form BEN043 by clicking the link below or browse more documents and templates provided by the Alaska Department of Administration.

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Download Form BEN043 "Authorization for the Use and/or Disclosure of Protected Health Information (Phi)" - Alaska

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Authorization for the
FOR OFFICE USE ONLY
Use and/or Disclosure of
Protected Health Information (PHI)
Division of Retirement and Benefits
Juneau: (907) 465-4460
Toll-Free: (800) 821-2251
P.O. Box 110203
TDD: (907) 465-2805
alaska.gov/drb
Juneau, Alaska 99811-0203
Fax: (907) 465-3086
MEMBER INFORMATION
Last Name
First Name
Middle Initial
Health Plan ID Number
Birthday (MM/DD/YYYY)
Daytime Telephone number (include area code)
(
)
What is the patient’s relationship to the member?  Self
 Spouse
 Child
 Other:
PATIENT INFORMATION
Last Name
First Name
Middle Initial
Health Plan ID Number
Birthday (MM/DD/YYYY)
Daytime Telephone number (include area code)
(
)
AUTHORIZED PERSON(S) OR ENTITY(S) TO WHOM ALASKACARE MAY RELEASE YOUR PHI
Person or entity authorized to receive PHI
Daytime Telephone number (include area code)
(
)
Street Address
City, State and Zip
Person or entity authorized to receive PHI
Daytime Telephone number (include area code)
(
)
Street Address
City, State and Zip
Person or entity authorized to receive PHI
Daytime Telephone number (include area code)
(
)
Street Address
City, State and Zip
Person or entity authorized to receive PHI
Daytime Telephone number (include area code)
(
)
Street Address
City, State and Zip
Person or entity authorized to receive PHI
Daytime Telephone number (include area code)
(
)
Street Address
City, State and Zip
Person or entity authorized to receive PHI
Daytime Telephone number (include area code)
(
)
Street Address
City, State and Zip
BEN043 (Rev. 12/21)
G:\Communications_Only\200 Products\206 Forms, Applications, Info Packets, Benefit Cards\Benefits\ben043.indd
Authorization for the
FOR OFFICE USE ONLY
Use and/or Disclosure of
Protected Health Information (PHI)
Division of Retirement and Benefits
Juneau: (907) 465-4460
Toll-Free: (800) 821-2251
P.O. Box 110203
TDD: (907) 465-2805
alaska.gov/drb
Juneau, Alaska 99811-0203
Fax: (907) 465-3086
MEMBER INFORMATION
Last Name
First Name
Middle Initial
Health Plan ID Number
Birthday (MM/DD/YYYY)
Daytime Telephone number (include area code)
(
)
What is the patient’s relationship to the member?  Self
 Spouse
 Child
 Other:
PATIENT INFORMATION
Last Name
First Name
Middle Initial
Health Plan ID Number
Birthday (MM/DD/YYYY)
Daytime Telephone number (include area code)
(
)
AUTHORIZED PERSON(S) OR ENTITY(S) TO WHOM ALASKACARE MAY RELEASE YOUR PHI
Person or entity authorized to receive PHI
Daytime Telephone number (include area code)
(
)
Street Address
City, State and Zip
Person or entity authorized to receive PHI
Daytime Telephone number (include area code)
(
)
Street Address
City, State and Zip
Person or entity authorized to receive PHI
Daytime Telephone number (include area code)
(
)
Street Address
City, State and Zip
Person or entity authorized to receive PHI
Daytime Telephone number (include area code)
(
)
Street Address
City, State and Zip
Person or entity authorized to receive PHI
Daytime Telephone number (include area code)
(
)
Street Address
City, State and Zip
Person or entity authorized to receive PHI
Daytime Telephone number (include area code)
(
)
Street Address
City, State and Zip
BEN043 (Rev. 12/21)
G:\Communications_Only\200 Products\206 Forms, Applications, Info Packets, Benefit Cards\Benefits\ben043.indd
PLAN NAME
NATURE OF PHI
 Medical
 Benefits, enrollment, premiums and eligibility
 Dental
 Claim
 Vision
 Health Appeal
 Health Flexible Spending Account
 Medical/Treatment/Diagnostic Records
 Other: (please specify) ______________________________
 Other: (please specify) ______________________________
REASON FOR USE AND/OR DISCLOSURE
The health information described above in Nature of PHI may be used only for the purpose(s) indicated here.
Name of Provider(s): _________________________________
 To resolve a benefits claim for the patient listed above for:
Date(s) of service: _______________________________
__________________________________________________
 To resolve an issue regarding the enrollment and coverage of:
__________________________________________________
 Myself
 My family member(s): ___________________________
 To obtain claims or other information in order to assist me or a family member in dealing with another insurance company.
 At the request of the individual (check this box if individual does not want to disclose reason for request).
 Other: _________________________________________________________________________________________________
IMPORTANT: Your signature below means that you understand and agree to the following:
• This authorization expires on: _____________________________
(An expiration date or an expiration event that relates to the individual or the purpose of the use or disclosure. If no expiration
date is listed, this authorization will expire two (2) years from the date of signature.)
• The phrase "medical records" as used in Nature of PHI includes but is not limited to physical health, mental health, treatment for
alcohol and/or drug abuse, sexually transmitted disease, acquired immunodeficiency syndrome (AIDS) or infection with Human
Immunodeficiency Virus (HIV).
• I understand that, if the person or entity I have authorized on this form to receive my PHI is not required to comply with federal
privacy protection regulations, my health information may be further disclosed and is no longer protected.
• I understand that I may revoke this authorization at any time by notifying the Plan in writing at the address on the front of this
form. I also understand that my revocation cannot affect any use and/or disclosure of protected health information based on this
authorization if it occurred before the Plan received my revocation letter.
• I understand that my eligibility for benefits and payment for services will not be affected if I do not sign this form. I also
understand that without my signature, my request to release the information described above to a third party will not be honored.
• You should retain a copy of this form for your records. You may also request a copy by writing to the address listed on the front
of this form.
• If we receive requests for copies of claims and other information from the individual or company you have authorized to receive
your confidential information, we may charge a reasonable fee (except where prohibited by law) for copying and mailing costs.
I authorize AlaskaCare to release my PHI as indicated on this form to the person(s) or entity(s) identified.
Signature of Patient or Legal Representative of Patient
Date
Print Name
Daytime Telephone number (include area code)
(
)
Must be signed by the person whose records are to be released, unless that person is under the age of 18 and is not emancipated.
If not the Patient, describe relationship to the Patient:
 Natural or Adoptive Parent of Unemancipated Minor Child
 Other Legal Representative (You must furnish a copy of the healthcare power of attorney or other legal document(s) designating
you as the legal representative.)
 Relationship to the patient, including authority for status as legal representative
BEN043 (Rev. 12/21)
G:\Communications_Only\200 Products\206 Forms, Applications, Info Packets, Benefit Cards\Benefits\ben043.indd
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