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_________________________________________________________________________________________________________

Authorization to Use and Disclose

Health Information

Notice to Member:

• Completing this form will allow Next Door Neighbors, Inc.’s subsidiary health plans, herein referred to as Ascension Complete to (i) use your health information for a particular purpose, and/or (ii) share your health information with the individual or entity that you identify on this form.

• You do not have to give permission to use or share your health information. Your services and benefits with Ascension Complete will not change if you do not submit this form.

• If you want to cancel this authorization form, send us a written request to revoke it at the address on the bottom of this page. A revocation form can be provided to you by calling Member Services at the phone number on the back of your member ID card.

• Ascension Complete cannot promise that the person or group you allow us to share your health information with will not share it with someone else.

• Keep a copy of all completed forms that you send to us. We can send you copies if you need them. • If you need help, contact Member Services at the phone number on the back of your member ID

card.

• Fill in all the information on this form. When finished, mail the form and any supporting documentation to

Ascension Complete ATTN: Privacy Officer PO Box 10420

Van Nuys, CA 91410

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_____________ (_____ ) ______ - ______ ____________________________ ________________________________ _________________________________ _________________________ ___________________________________________________________ ________ _______________ ________________________________________________________________________ ___________________________________________________________ ___________________ PLEASE READ THE INSTRUCTIONS CAREFULLY AND COMPLETE THE FORM BELOW. INCOMPLETE FORMS CANNOT BE ACCEPTED.

1

MEMBER INFORMATION:

Member Name (print): ___________________________________________________________________________ Member Date of Birth: __________________ Member ID Number: ____________________________________

2

I GIVE ASCENSION COMPLETE PERMISSION TO USE MY HEALTH INFORMATION FOR THE PURPOSE IDENTIFIED OR TO SHARE MY HEALTH INFORMATION WITH THE

PERSON OR GROUP NAMED BELOW. THE PURPOSE OF THE AUTHORIZATION IS (check

one option below):

□ to allow Ascension Complete to help me with my benefits and services, OR □ to permit Ascension Complete to use or share my health information for

3

PERSON OR GROUP TO RECEIVE INFORMATION (add more Persons or Groups on next page): Name (person or group):

Address:

City: State: Zip: Phone:

4

I AUTHORIZE ASCENSION COMPLETE TO USE OR SHARE THE FOLLOWING HEALTH INFORMATION (NOTE: Select the first statement to release ALL health information or select the

below statement to release only SOME health information. Both CANNOT be selected.) □ All of my health information INCLUDING:

Genetic information, services or test results; HIV/AIDS data and records; mental health data and records (but not psychotherapy notes); prescription drug/medication data and records; and drug and alcohol data and records (please specify any substance use disorder information that may be disclosed);

OR

□ All of my health information EXCEPT (check only the boxes below that apply): □ Genetic information, services or tests

□ AIDS or HIV data and records □ Drug and alcohol data and records

□ Mental health data and records (but not psychotherapy notes) □ Prescription drug/medication data and records

□ Other:

5

THIS AUTHORIZATION ENDS ON THIS DATE/EVENT:

Date this authorization ends unless cancelled. If this field is blank, the authorization expires one year from the date of the signature below.

6

MEMBER OR LEGAL REPRESENTATIVE SIGNATURE: DATE:

IF LEGAL REPRESENTATIVE - Relationship to Member:

If you are the Member’s legal or personal representative, you must send us copies of relevant forms, such as power of attorney or order of guardianship.

MA IL COMPLETED AUTHORIZATION FORM AND ANY SUPPORTING DOCUMENTATION TO Ascension Complete, ATTN: Privacy Officer

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( ) ( ) -( ) ( ) ( ) -( ) ( ) ( )

ADDITIONAL INDIVIDUAL PERSON(S) OR GROUP(S) TO RECEIVE INFORMATION:

NOTE: If you are consenting to disclose any substance use disorder records to a recipient that is neither a third party payor nor a health care provider, facility, or program where you receive services from a treating provider, such as a health insurance exchange or a research institution (hereafter, “recipient entity”), you must specify the name of an individual with whom or the entity at which you receive services from a treating provider at that recipient entity, or simply state that your substance use disorder records may be disclosed to your current and future treating providers at that recipient entity.

Name (individual or entity): Address:

City: State: Zip: Phone:

Name (individual or entity): Address:

City: State: Zip: Phone:

Name (individual or entity): Address:

City: State: Zip: Phone:

Name (individual or entity): Address:

City: State: Zip: Phone:

Name (individual or entity): Address:

City: State: Zip: Phone:

Name (individual or entity): Address:

City: State: Zip: Phone:

Name (individual or entity): Address:

City: State: Zip: Phone:

Name (individual or entity): Address:

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If you need these services, contact Ascension Complete's Member Services at: For Alabama: 1­833­623­0771; For Florida: 1-833-603-2971; For Illinois: 1-833-293-5966; For Indiana: 1­833­525­0824; For Kansas: 1-833-816-6623; For Michigan: 1­833­431­1356; For Tennessee: 1­833­906­2876 (TTY: 711). From October 1 to March 31, you can call us 7 days a week

from 8 a.m. to 8 p.m. From April 1 to September 30, you can call us Monday through Friday

from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays.

Section 1557 Non-Discrimination Language Notice of Non-Discrimination

Ascension Complete complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Ascension Complete:

Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats).

 Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages.

If you believe that Ascension Complete has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; Ascension Complete’s Member Services is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019 (TDD: 1-800-537-7697).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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English: Language assistance services, auxiliary aids and services, and other alternative formats are available to you free of charge. To obtain this, please call the number above.

Español (Spanish): Servicios de asistencia de idiomas, ayudas y servicios auxiliares, y otros formatos alternativos están disponibles para usted sin ningún costo. Para obtener esto, llame al número de arriba.

Kreyòl (French Creole): W ap jwenn gratis sèvis tradiksyon, èd ak sèvis siplemantè, ak lòt fòma altènatif san w pa peye pou yo. Tanpri sonnen nan nimewo ki make anlè a pou w resevwa sa.

Polski (Polish): Dostępne są również bezpłatnie: pomoc językowa, dodatkowe pomoce i usługi oraz inne alternatywne formaty. Aby je uzyskać, proszę zadzwonić numer wskazany powyżej.

简体中文 (Chinese):可以免费为您提供语言协助服务、辅助用具和服务以及其他格式。如有需要,请

拨打上述电话号码。

Tiếng Việt (Vietnamese): Các dịch vụ trợ giúp ngôn ngữ, các trợ cụ và dịch vụ phụ thuộc, và các dạng thức thay thế khác hiện có miễn phí cho quý vị. Để có được những điều này, xin gọi số điện thoại nêu trên.

Tagalog (Tagalog): Mayroon kang makukuhang libreng tulong sa wika, auxiliary aids at mga serbisyo, at iba pang mga alternatibong format. Upang makuha ito, mangyaring tawagan ang numerong nakasulat sa itaas.

Français (French) : Des services gratuits d’assistance linguistique, ainsi que des services

d’assistance supplémentaires et d’autres formats sont à votre disposition. Pour y accéder, veuillez appeler le numéro ci-dessus.

한국어 (Korean): 언어 지원 서비스 , 보조적 지원 및 서비스 , 기타 형식의 자료를 무료로 이용하실 수 있습니다 . 이용을 원하시면 상기 전화번호로 연락해 주십시오 . Русский язык (Russian): Вам могут быть бесплатно предоставлены услуги по переводу, вспомогательные средства и услуги, а также материалы в других, альтернативных, форматах. Чтобы получить их, позвоните, пожалуйста, по указанному выше номеру телефона. .ﻣﺟﺎﻧﺎ ﻟك ﻣﺗﺎﺣﺔ اﻟﺑدﻳﻠﺔ اﻷﺷﻛﺎل ﻣن وﻏﻳرﻫﺎ اﻹﺿﺎﻓﻳﺔ واﻟﺧدﻣﺎت واﻟﻣﻌﻳﻧﺎت اﻟﻠﻐوﻳﺔ اﻟﻣﺳﺎﻋدة ﺧدﻣﺎت :(Arabic) اﻟﻌرﺑﯾﺔ أﻋﻼه ﺑﺎﻟرﻗم اﻻﺗﺻﺎل ﻳرﺟﻰ ﻋﻠﻳﻬﺎ،اﻟﻌرﺑﻳﺔ ﻟﻠﺣﺻوﻟ Português (Portuguese): Serviços de assistência linguística, ajudas e serviços auxiliares e outros formatos alternativos estão disponíveis gratuitamente para você. Para os obter, ligue para o número indicado acima.

Deutsch (German): Sprachunterstützung, Hilfen und Dienste für Hörbehinderte und Gehörlose sowie weitere alternative Formate werden Ihnen kostenlos zur Verfügung gestellt. Um eines dieser Serviceangebote zu nutzen, wählen Sie die o. a. Rufnummer.

Italiano (Italian): Sono disponibili gratuitamente servizi di interpretariato/traduzione, ausili e servizi accessori nonché altri formati alternativi. Per ottenerli, chiamare il numero di telefono riportato sopra.

اﺳﮯ ﮨﯿﮟ۔ دﺳﺘﯿﺎب ﻣﻔﺖ ﻟﯿﮯ ﮐﮯ آپ ﺷﮑﻠﯿﮟ ﻣﺘﺒﺎدﻟ دﯾﮕﺮ اور ،ﺧدﻣﺎت اور ذراﺋﻊ ﮐﮯ اﻣداد ،ﺧدﻣﺎت ﮐﯽ اﻋﺎﻧﺖ ﮐﯽ زﺑﺎن :(Urdu) اردو ﮐﺮﯾﮟ۔ ﮐﺎل پﺮ ﻧﻤﺒﺮ دﺮج اوپﺮ ﮐﺮﮐﮯ ﻣﮩﺮﺑﺎﻧﯽ ،ﻟﯿﮯ ﮐﮯ ﮐﺮﻧﮯ ﺣﺎﺻﻞ Y0020_20_13607MLI_C_07222019

References

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