Mpiphp forms 2025

1. Click ‘Get Form’ to open the mpiphp form in the editor.
2. Begin by entering your full name in the designated field, selecting whether you are a participant, spouse, or dependent. Provide your date of birth and either your Participant ID or the last four digits of your Social Security Number.
3. Fill in your address, including street, city, state, and ZIP code. Don’t forget to include both daytime and home phone numbers along with your email address.
4. In section 1, specify the health information you wish to disclose by checking all applicable boxes. If necessary, provide details about specific health claims.
5. Designate the person or organization authorized to receive your health information in section 2. Ensure you provide their full names for clarity.
6. Indicate the reason for disclosure in section 3 by checking one of the options provided.
7. Select when you would like this authorization to expire in section 4. Choose from the options available based on your preference.
8. Review your rights regarding this authorization before signing at the bottom of the form. Ensure all information is accurate before submitting.

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