"Authorization for the Release of Medical Information" - Maryland

Authorization for the Release of Medical Information is a legal document that was released by the Maryland Attorney General - a government authority operating within Maryland.

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Authorization for the Release of Medical Information
By signing this form, I either wish to file a complaint, or I authorize a health care provider to file a complaint on my
behalf, with the Health Education and Advocacy Unit (HEAU) of the Office of the Attorney General and/or the Maryland
Insurance Administration (MIA).
I authorize the HEAU and/or the MIA to contact my health care providers, my insurance carrier, HMO, and other State or
Federal government agencies, to obtain any medical records, mental health or substance abuse records, and/or insurance
information related to the complaint filed by me or on my behalf. I authorize my health care providers and insurance
carriers to release any medical records, mental health or substance abuse records, and/or insurance information relevant
to the complaint filed by me or on my behalf to the HEAU and/or the MIA. I understand that my treatment, payment,
enrollment, or eligibility for benefits under my health plan may not be conditioned upon whether I sign this
Authorization. However, I understand that the HEAU and MIA will be unable to process my complaint if I fail to sign
this Authorization.
I authorize the HEAU and/or the MIA to release or redisclose my medical record and other information related to my
complaint to my health care providers, my insurance carrier, HMO, and other State or Federal government agencies that
may assist in the resolution of my complaint. I authorize the HEAU to assist me by mediating my complaint, filing a
grievance or appeal with my insurance carrier, or by filing a complaint with the MIA or other State or Federal
government agencies that may assist in the resolution of my complaint.
If my complaint is referred to or filed with MIA, I authorize MIA to release my medical records to health care providers,
my insurance carrier, HMO, independent review organizations, medical experts and other government agencies or
contractors that may assist in the resolution of my complaint.
There is the potential for information provided to be subject to redisclosure in the process of investigating the complaint
and pursuing any action required as a result of the complaint investigation, in which case the information may no longer
receive privacy protection under Federal law. I understand that information about my experience may be used to develop
statistical information on the health care marketplace in Maryland or to examine the quality of care of an HMO, but the
confidentiality of my identity and medical records will be protected in accordance with Maryland and Federal law.
This authorization is valid for one year. It shall be automatically revoked once the complaint has been resolved. I
understand that I may revoke this Authorization at any time by notifying the Health Education and Advocacy
Unit or the Maryland Insurance Administration, if my complaint has been referred to or filed with MIA, which
will provide me with a form to sign confirming my revocation. A copy of the revocation will be provided to each
party to whom this Authorization was provided. I understand that the revocation will not apply to the extent that
a health care provider and/or insurance carrier has taken action in reliance on this authorization.
__________________________________________
_________________________________________________
Signature
Date
el
______________________________________________________________________________________
Relationship: If the person signing this release is not the patient, please give the relationship to the patient.
_________________________________________
______________________________________________
Patient Name
Patient’s Date of Birth
_________________________________________
Patient’s Health Insurance Membership #
PLEASE NOTE: All patients 18 years of age and over must sign this consent form themselves, unless they have a legal
guardian, personal representative, are incapacitated or have otherwise delegated authority to complete this form. If so, the
signer must submit written proof of guardianship, representation, incapacity or other delegation of authority with this consent
form. A parent or guardian must sign on behalf of an unemancipated minor, except in certain circumstances. Where Maryland
law allows a person under 18 to consent to health care treatment without the consent of a parent or guardian, only the signature
of the patient is necessary.
___________________________________
__________________________________
Authorization for the Release of Medical Information
By signing this form, I either wish to file a complaint, or I authorize a health care provider to file a complaint on my
behalf, with the Health Education and Advocacy Unit (HEAU) of the Office of the Attorney General and/or the Maryland
Insurance Administration (MIA).
I authorize the HEAU and/or the MIA to contact my health care providers, my insurance carrier, HMO, and other State or
Federal government agencies, to obtain any medical records, mental health or substance abuse records, and/or insurance
information related to the complaint filed by me or on my behalf. I authorize my health care providers and insurance
carriers to release any medical records, mental health or substance abuse records, and/or insurance information relevant
to the complaint filed by me or on my behalf to the HEAU and/or the MIA. I understand that my treatment, payment,
enrollment, or eligibility for benefits under my health plan may not be conditioned upon whether I sign this
Authorization. However, I understand that the HEAU and MIA will be unable to process my complaint if I fail to sign
this Authorization.
I authorize the HEAU and/or the MIA to release or redisclose my medical record and other information related to my
complaint to my health care providers, my insurance carrier, HMO, and other State or Federal government agencies that
may assist in the resolution of my complaint. I authorize the HEAU to assist me by mediating my complaint, filing a
grievance or appeal with my insurance carrier, or by filing a complaint with the MIA or other State or Federal
government agencies that may assist in the resolution of my complaint.
If my complaint is referred to or filed with MIA, I authorize MIA to release my medical records to health care providers,
my insurance carrier, HMO, independent review organizations, medical experts and other government agencies or
contractors that may assist in the resolution of my complaint.
There is the potential for information provided to be subject to redisclosure in the process of investigating the complaint
and pursuing any action required as a result of the complaint investigation, in which case the information may no longer
receive privacy protection under Federal law. I understand that information about my experience may be used to develop
statistical information on the health care marketplace in Maryland or to examine the quality of care of an HMO, but the
confidentiality of my identity and medical records will be protected in accordance with Maryland and Federal law.
This authorization is valid for one year. It shall be automatically revoked once the complaint has been resolved. I
understand that I may revoke this Authorization at any time by notifying the Health Education and Advocacy
Unit or the Maryland Insurance Administration, if my complaint has been referred to or filed with MIA, which
will provide me with a form to sign confirming my revocation. A copy of the revocation will be provided to each
party to whom this Authorization was provided. I understand that the revocation will not apply to the extent that
a health care provider and/or insurance carrier has taken action in reliance on this authorization.
__________________________________________
_________________________________________________
Signature
Date
el
______________________________________________________________________________________
Relationship: If the person signing this release is not the patient, please give the relationship to the patient.
_________________________________________
______________________________________________
Patient Name
Patient’s Date of Birth
_________________________________________
Patient’s Health Insurance Membership #
PLEASE NOTE: All patients 18 years of age and over must sign this consent form themselves, unless they have a legal
guardian, personal representative, are incapacitated or have otherwise delegated authority to complete this form. If so, the
signer must submit written proof of guardianship, representation, incapacity or other delegation of authority with this consent
form. A parent or guardian must sign on behalf of an unemancipated minor, except in certain circumstances. Where Maryland
law allows a person under 18 to consent to health care treatment without the consent of a parent or guardian, only the signature
of the patient is necessary.
___________________________________
__________________________________