Form DE-202 Authorization to Disclose Protected Health Information to Ahcccs - Arizona

Preview

Fill PDF Online

PDF

Word

Fill PDF Online

Fill out online for free

without registration or credit card

What Is Form DE-202?

This is a legal form that was released by the Arizona Health Care Cost Containment System - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is Form DE-202?
A: Form DE-202 is an Authorization to Disclose Protected Health Information (PHI) to AHCCCS in Arizona.

Q: What is AHCCCS?
A: AHCCCS stands for Arizona Health Care Cost Containment System, which is Arizona's Medicaid program.

Q: Why would I need to fill out Form DE-202?
A: You would need to fill out Form DE-202 to authorize the release of your protected health information to AHCCCS for purposes related to your healthcare coverage and benefits.

Q: What information does Form DE-202 require?
A: Form DE-202 requires your personal information, such as your name, address, and social security number, as well as specific details about the information being disclosed and the purpose of the disclosure.

Q: Who should I contact if I have questions about Form DE-202?
A: You should contact AHCCCS directly if you have any questions or concerns about Form DE-202 or the authorization process.

Form Details:

Released on September 1, 2022;
The latest edition provided by the Arizona Health Care Cost Containment System;
Easy to use and ready to print;
Available in Spanish;
Quick to customize;
Compatible with most PDF-viewing applications;
Fill out the form in our online filing application.

Download a fillable version of Form DE-202 by clicking the link below or browse more documents and templates provided by the Arizona Health Care Cost Containment System.