Give another person or organization permission to access your health information 2025

1. Click ‘Get Form’ to open it in the editor.
2. In SECTION 1, enter your personal details including your name, member ID number, address, date of birth, and preferred phone number. Indicate if messages can be left.
3. Move to SECTION 2 where you specify the health information you are authorizing for disclosure. Clearly state the purpose of this authorization by checking applicable boxes such as 'Payment of claims' or 'Coordinating care for dependent/spouse'.
4. Provide the details of the person or organization receiving access in SECTION 2. Include their name, address, and contact information.
5. In SECTION 3, read through the terms carefully. Sign and date the form to confirm your authorization. If applicable, attach any necessary documentation for a personal representative.

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