"Authorization for Release of Protected Health Information From the Delaware Employee Health Care Plan" - Delaware

This Delaware-specific "Authorization for Release of Protected Health Information From the Delaware Employee Health Care Plan" is a document released by the Delaware Department of Human Resources.

Download the fillable PDF by clicking the link below and use it according to the applicable legal guidelines.

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Download "Authorization for Release of Protected Health Information From the Delaware Employee Health Care Plan" - Delaware

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STATE OF DELAWARE
A
F
R
O
P
H
I
UTHORIZATION
OR
ELEASE
F
ROTECTED
EALTH
NFORMATION
D
FROM THE
ELAWARE EMPLOYEE HEALTH CARE PLAN
[
-
]
PLEASE CHECK THE APPROPRIATE BOXES AND FILL
IN THE BLANKS
Section 1: Person whose health information will be disclosed: [please print]
Name: _____________________________________________________________________________________
Address: ___________________________________________________________________________________
City and State: _______________________________________________________________________________
Health Plan ID #: ____________________________________________________________________________
Group #: ___________________________________________________________________________________
Telephone Number: __________________________________________________________________________
Birth Date: __________________________________________________________________________________
Section 2: Person or Entity that has the health information to be released:
_________________________________________ [please print the name of the entity that has the record to be
disclosed; e.g., Health Plan, Dr. Jane Doe, ABC Laboratories, etc.]
Section 3: Description of the health information to be released:
All information related to the claim for medical services or treatment described below.
Claim Number(s): ____________________ Date(s) of Service: __________________
Provider(s) Name: _______________________________________________________
If “information related to a sensitive” diagnosis is to be disclosed, the pertinent boxes must be checked:
Substance Abuse
HIV/AIDS
Genetic Testing
Mental Health Care
[Please note that the types of information to be disclosed by the Plan include: explanation of benefits (EOB) forms,
claims history, eligibility determinations, information related to payment of claims or coordination of benefits,
medical records obtained and/or reviewed with regard to claims or appeals, and other information that the Plan
may have used to make decisions about your eligibility for benefits or the payment of your claims.]
Section 4: Person or Entity that will receive the health information: Representatives of the Statewide Benefits
Office and other State Delegates involved in the health plan appeal or claim(s) review request.
I authorize the Statewide Benefits Office and other State Delegates to release protected health information to the
following person (“Representative”):
Name: __________________________________
Relationship to member: ________________________
Best contact telephone number: _________________________________
I further authorize the Statewide Benefits Office and other State Delegates to share protected health information with
each other and my Representative as necessary for the purpose of my health plan appeal or claim(s) review request.
A written response will be provided to all members who have submitted a request for a Level III appeal request.
Your Initials: ________ Date: _____________
Page 1 of 2
STATE OF DELAWARE
A
F
R
O
P
H
I
UTHORIZATION
OR
ELEASE
F
ROTECTED
EALTH
NFORMATION
D
FROM THE
ELAWARE EMPLOYEE HEALTH CARE PLAN
[
-
]
PLEASE CHECK THE APPROPRIATE BOXES AND FILL
IN THE BLANKS
Section 1: Person whose health information will be disclosed: [please print]
Name: _____________________________________________________________________________________
Address: ___________________________________________________________________________________
City and State: _______________________________________________________________________________
Health Plan ID #: ____________________________________________________________________________
Group #: ___________________________________________________________________________________
Telephone Number: __________________________________________________________________________
Birth Date: __________________________________________________________________________________
Section 2: Person or Entity that has the health information to be released:
_________________________________________ [please print the name of the entity that has the record to be
disclosed; e.g., Health Plan, Dr. Jane Doe, ABC Laboratories, etc.]
Section 3: Description of the health information to be released:
All information related to the claim for medical services or treatment described below.
Claim Number(s): ____________________ Date(s) of Service: __________________
Provider(s) Name: _______________________________________________________
If “information related to a sensitive” diagnosis is to be disclosed, the pertinent boxes must be checked:
Substance Abuse
HIV/AIDS
Genetic Testing
Mental Health Care
[Please note that the types of information to be disclosed by the Plan include: explanation of benefits (EOB) forms,
claims history, eligibility determinations, information related to payment of claims or coordination of benefits,
medical records obtained and/or reviewed with regard to claims or appeals, and other information that the Plan
may have used to make decisions about your eligibility for benefits or the payment of your claims.]
Section 4: Person or Entity that will receive the health information: Representatives of the Statewide Benefits
Office and other State Delegates involved in the health plan appeal or claim(s) review request.
I authorize the Statewide Benefits Office and other State Delegates to release protected health information to the
following person (“Representative”):
Name: __________________________________
Relationship to member: ________________________
Best contact telephone number: _________________________________
I further authorize the Statewide Benefits Office and other State Delegates to share protected health information with
each other and my Representative as necessary for the purpose of my health plan appeal or claim(s) review request.
A written response will be provided to all members who have submitted a request for a Level III appeal request.
Your Initials: ________ Date: _____________
Page 1 of 2
STATE OF DELAWARE
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
FROM THE DELAWARE EMPLOYEE HEALTH CARE PLAN
Section 5: Description of the purpose for the release of the health information:
At the request of the person whose name appears in Section 1
To obtain assistance with adjudication, payment and/or appeal of pending Plan claims
To support a claim for non-health benefits, such as disability benefits, workers compensation benefits or life
insurance benefits
Other [insert description of the purpose]: ________________________________________
Section 6: Duration of Authorization: This Authorization will remain effective [choose an expiration period or
event]:
will expire on _______________________ (date)
for the duration of the review by the Statewide Benefit Office but not greater than one year after date of member’s
signature
Other (please specify) _________________________________________________________
If no date, event or circumstance is included, this Authorization will expire one year after date of member signature.
Section 7: Certification and Acknowledgement: I certify that I am the person (or the personal representative of the
person) designated in Part 1. I agree that my individually identifiable health information described in Part 3, and held
by the person or entity listed in Part 2, may be disclosed to the person or entity listed in Part 4 for the purpose(s)
designated in Part 5.
I understand that the State of Delaware Employee Health Care Plan will not condition treatment, payment, enrollment
or eligibility on the provision of this Authorization. I understand that I have the right to revoke this Authorization, in
writing, at any time, by sending the revocation to the State of Delaware Employee Health Care Plan, Privacy Officer,
97 Commerce Way, Suite 201, Dover, Delaware, 19904, and that the revocation will be effective except to the extent
that the Delaware Employee Health Care Plan has already taken action in reliance on my Authorization. I understand
that, once disclosed, it is possible that the health information may be further disclosed by the recipient and no longer
subject to protection under federal privacy rules.
I have received a copy of my signed Authorization.
Signature: __________________________________________________ Date: ___________________
Daytime Telephone: __________________________ Email Address: _________________________________
(If signing as the personal representative of the person in Section 1, print your name and describe your authority to
sign for the person and attach any legal documentation which authorizes signature on the member’s behalf (power of
Attorney, Guardianship, etc.).
Name:____________________________________________Authority: __________________________________
Submit this Completed Form to the Statewide Benefits Office (SBO) by secure email (benefits@state.de.us),
fax (302-739-8339) or by mail (97 Commerce Way, Suite 201, Dover, DE 19904).
For office use:
Authorization fully completed and signed
Copy of Authorization provided to Individual or Personal Representative
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