Authorization for Release of Records or Information
Background: New Federal regulations
regarding the privacy of individual medical history prohibits
medical service providers, insurance companies, and other entities
that may have such information from releasing it to third parties.
This includes information about medical claims that could be needed
to resolve a medical claim issue.
Purpose: To allow an insured to
authorize a third party to access a specific part of their medical
history from a specific group. This authorization to access
information is limited by:
- The Information Holder - Information can only
be released by the information holder authorized by the Insured.
- The Personal Health Information To Be Disclosed
- Only the specific information indicated on the form by the
Insured can be released to the third party.
- Persons/Entities Authorized to Receive and Use
- Only the third party indicated on the form can receive the
information released.
- Purpose of the Disclosure - The reason the
Insured wants to allow the third party access to the information,
and how the third party is allowed to use the information.
- Right to Revoke - The Insured has the ability
to revoke the right to the information access at any time.
Additional Information:
- Since the authorization to release information
is restricted by the above, a new release form will need to be
completed for each claim resolution request, and more than one
release form (one for the medical service provider and one for the
insurance company) may need to be completed per claim.
- The forms available here are (or are created
upon) the actual HIPAA forms. NCAS and some medical service
providers accept these forms. In regard to this,
it is important to note:
- "Plan" as indicated in Section A would be the
entity that holds the information you authorize to be released.
If it is a medical service provider, it would be the provider's
name (i.e., Smith Medical Practice). If it is an insurance
carrier, it would be the plan name (i.e., CareFirst Blue
Preferred).
- You may want to check with your medical
service provider prior to requesting Benefit Choices assist you
with a claim, to verify if the standard HIPAA release form is
adequate or if they have their own release form that must be
completed.
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