Value options authorization disclose health information 2025

1. Click ‘Get Form’ to open it in the editor.
2. In Section 1, enter the name, Member ID, date of birth, and phone number of the individual whose health information is being disclosed.
3. Proceed to Section 2. Identify the person or entity receiving the information by providing their name, contact details, and reason for disclosure. Ensure you include a phone number for follow-up.
4. In Section 3, indicate which specific types of health information you authorize for release by initialing the relevant boxes. You may also specify any limitations regarding the information being disclosed.
5. Section 4 requires you to specify how long this authorization will remain in effect. You can choose one year or provide a specific expiration date.
6. Finally, review your rights outlined in Section 5 before signing and dating the form at the bottom. If applicable, attach any legal documents if you are signing on behalf of someone else.

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