Consent to Release Health Information

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Consent to Release Health Information

Sometimes you need to see a number of different providers to get all the services you require. This includes behavioral

health providers and physical health providers. All of your providers and managed care organizations should work together

to provide you with the best possible care, but your providers and managed care organizations can only talk to each other

with your permission. Please consider giving this permission. Allowing your providers and managed care organizations to

talk to each other about your care will help ensure that you are receiving all the care you need.

This form was developed in collaboration with physical health managed care organizations and the Department of Human

Services. By signing this form, you are telling us that it is OK for your primary care provider, your behavioral health care

providers, your physical health managed care organization and your behavioral health managed care organization to share

health information about you for the purpose of planning and coordinating your health care. This helps your providers

and managed care companies work together to take better care of you.

If you do not sign this form your benefits will stay the same. Some information may still be shared even if you do not sign

this consent form, but only as otherwise permitted by law. If you have questions about your rights or if you need more

details about how your health information is shared, please call the member services number on the back of your behavioral

or physical health managed care ID card or in your member handbook.

Part 1 Member Information

Last Name First Name Middle Initial

Medical Assistance ID number - MAID# (full 10- digits)

Date of Birth (MM/DD/YYYY) Phone Number (with area code)

Address City State Zip Code

Part 2 Who can my health information be given to?

This Consent to Release Information is being requested by:

Organization Name: Phone Number (with area code):

Address

Signature of staff member obtaining Member’s consent: Date

I agree that my health information can be shared with my primary care physician (PCP) below:

Primary Care Provider (PCP) Name: Phone Number (with area code):

Address

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I agree that my health information can be shared with the other physical health or behavioral health

provider(s) below (if you have more than one physical health or behavioral health provider):

Physical/Behavioral Health Care Provider Name: Phone Number (with area code): Address

I agree that my health information can be shared with my physical health or behavioral health managed

care organization below. Please check your managed care organization(s):

Behavioral Health Managed Care Organizations  Community Behavioral Health, Inc

 Community Care Behavioral Health Organization

 Community Behavioral HealthCare Network of Pennsylvania (CBHNP)  Magellan Behavioral Health

 Value Behavioral Health  Other (please specify):

Physical Health Managed Care Organizations  Aetna

 AmeriHealth Caritas PA  AmeriHealth Caritas NE  Keystone First

 Gateway Health Plan  Geisinger Health Plan  HealthPartners  United Healthcare  UPMC Health Plan  Other (please specify):

Part 3 Why are you sharing this health information?

Sharing this information allows your physical health and behavioral health managed care organizations and providers to better manage and coordinate your health care. While the health care plan developed will be unique to your own needs, some common goals include, but are not limited to: (1) making sure the medications that you are taking are safe to take together; (2) coordinating the health care services you are receiving; and (3) making sure the health care you are receiving is helping to keep you healthy and well.

Part 4 What health information can we share?

My general physical and mental health information will be shared if I sign this form.

IF my medical records include drug and/or alcohol treatment information and I am OK with that information being shared, the attached

Addendum A will be completed.

IF my medical records include HIV-related information and I am OK with that information being shared, the attached Addendum B will

be completed.

Part 5 I understand that:

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Part 6 Signature of Member

 Signing this form is voluntary. Even if I do not sign this form my benefits will be the same and I will still get treatment that I need.  My permission (OK) lasts for two years from when I sign this form. It also ends if I take back my OK, whichever happens first.  Some recipients of my medical information may not be subject to federal or state privacy laws, including HIPAA. My medical

information that is shared because I sign this form may therefore not be protected by those laws and could be shared again by those who receive it.

 This form does not include permission (OK) to share any drug and/or alcohol treatment information or HIV-related information in my records. If I want to allow that information to be shared with the Providers and Organizations named in Part 2 of this form, I must also give my separate permission (OK) in writing to share that specific information. I can give my permission (OK) to share such additional information in my records by filling out and signing the attached Addendum A (drug and/or alcohol treatment information) and/or Addendum B (HIV-related information).

By signing below I acknowledge that I have read and understand this form and I give my permission (OK) to share my health information as described.

Signature or mark of Member* Date

*For a Member who is physically unable to provide a signature, please complete Part 8 of this Form.

Part 7 Signature of Authorized Representative (if any)

If a member is under 18 years of age, is not legally emancipated and was not able to consent to treatment received on his/her own, the release of health information mentioned above requires the member’s parent’s/legal guardian’s consent. If the information to be shared is a mental health record, a member who is between 14 and 17 years of age and who understands (a) the nature of the information to be released and (b) the purpose for such release may consent to its release without the consent of his/her parent or legal guardian. If a parent/guardian has previously provided consent to mental health treatment for a member between the ages of 14 and 17, the

parent/guardian may consent to the release of said mental health records from one provider to another without the consent of the member. If this consent form is signed by someone who is not the member listed at the beginning of this consent form, attach any docu ments (e.g. general power of attorney) that verifies the signer’s legal authority to act for and on behalf of the member.

Signature of Member’s Authorized Representative Relationship to Member

Printed Name Date

Address:

Phone:

Witness:

Signature Date

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Part 8 Verbal consent by Member physically unable to provide a signature

For a Member who is physically unable to provide a signature, two responsible persons must bear witness that the Member both understands the nature of this Consent and that the Member freely gave verbal consent (OK) to share his/her information as de scribed.

By signing below, I witness that the Member is physically unable to provide a signature but that he/she understands the nature of this Consent and freely gives his/her verbal consent (OK) to share his/her information as described.

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Addendum A to Consent to Release Health Information

Drug and/or Alcohol Treatment Information

The health information that you agreed to release by signing the Consent to Release Health Information form may include drug and/or alcohol treatment information. Drug and/or alcohol treatment information requires additional consent by you to release those records. If your records have drug and/or alcohol treatment information, do you agree to share that information with the providers and

organization(s) listed in Part 2 of the Consent to Release Health Information form?

□ Yes, I agree. If you say yes, certain drug and/or alcohol treatment information that is in your records will be shared with the providers and organization(s) listed in Part 2 of the Consent to Release Health Information form.

□ No, I do not agree. If you say no, any drug and/or alcohol treatment information that is in your records will not be shared with any of the providers listed in Part 2 of the Consent to Release Health Information form.

Member Information

Signature of Member

My consent (OK) lasts for two years from the date I sign this form. I may revoke my consent at any time by writing to the organization who requested my consent, listed in Part 2 of the Consent to Release Health Information. If I am physically unable to communicate my revocation in writing, I can revoke or cancel my permission verbally by calling the member services number listed on the back of my behavioral or physical health managed care ID card or in my member handbook.

I give my permission (OK) to share the drug and/or alcohol treatment health information as described in this Addendum.

*For a Member who is physically unable to provide a signature, please complete the Verbal consent section on the next page.

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Signature of Authorized Representative (if any)

If the member is under 18 years of age, is not legally emancipated and was not able to consent to the treatment received on his/her own, the release of medical health care records requires the member’s parent/guardian consent.

If this consent is signed by someone who is not the member listed at the top of this consent, attach any documents (e.g., general power of attorney) that verify the signer’s authority to act for the member.

Printed Name Date

Address:

Phone: Witness:

Signature Date

Printed Name:

Verbal consent by Member physically unable to provide a signature

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Addendum B to Consent to Release Health Information

HIV-related Information

The health information that you agreed to release by signing the Consent to Release Health Information form may include HIV-related information. HIV-related information requires additional consent by you to release those records.

If your records have HIV-related information, do you agree to share that information with the providers and organization(s) listed in Part 2 of the Consent to Release Health Information form?

□ Yes, I agree. If you say yes, all HIV-related information that is in your records will be shared with the providers and organization(s) listed in Part 2 of the Consent to Release Health Information form.

□ No, I do not agree. If you say no, any HIV-related information that is in your records will not be shared with any of the providers and organization(s) listed in Part 2 of the Consent to Release Health Information form.

Member Information

Signature of Member

My consent (OK) lasts for two years from the date I sign this form. I may revoke my consent at any time by writing to the organization who requested my consent, listed in Part 2 of the Consent to Release Health Information. If I am physically unable to commun icate my revocation in writing, I can revoke or cancel my permission verbally by calling the member services number listed on the back of my behavioral or physical health managed care ID card or in my member handbook.

I give my permission (OK) to share the HIV-related health information as described in this Addendum.

I understand that once a person or organization receives my HIV information, with or without my consent, that person or organ ization may not give that information to anyone else without my written approval, or unless the law requires it.

*For a Member who is physically unable to provide a signature, please complete the Verbal consent section on the next page.

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Signature of Authorized Representative (if any)

If the member is under 18 years of age, is not legally emancipated and was not able to consent to the treatment received on his/her own, the release of medical health care records requires the member’s parent/guardian consent.

If this consent is signed by someone who is not the member listed at the top of this consent, attach any documents (e.g., general power of attorney) that verify the signer’s authority to act for the member.

Printed Name Date

Address:

Phone: Witness:

Signature Date

Printed Name:

Consent to Release Health Information

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