I authorize the use and disclosure of my individually identifiable medical or health information to Reconcile Care Management Services, (RCMS) and/or their agents, representatives or independent contractors for the purposes of administering Care/Disease Management Services.
I specifically authorize physicians, nurses and hospitals to communicate my individually identifiable medical or health information by any means, including written or telephonic communications or by direct interview, whether or not I am present during, or notified of, such communication, and I hereby authorize RCMS to initiate and conduct such communications whether or not I am present or have received notice thereof.
What Information is covered by this Authorization? This authorization applies to all medical and non-medical information that is needed by RCMS related to Care/Disease Management Services. My information to be disclosed may include, but is not limited to, medical or health history, (but not psychotherapy notes) chart notes, prescriptions, diagnostic test results, x-ray reports, records received from other health care providers, information regarding pre-existing health or medical conditions or illnesses.
1.Who may disclose and receive information under this Authorization?
A. Any person or facility that attends, treats or examines me, any pharmacy benefits manager, any insurance company, insurance support organization, employer, any group policy holder, contract holder or benefit plan administrator to disclose or any other person or organization that possesses any information described above, is authorized to make this information available to RCMS and or any of their agents, representatives or independent contractors.
B. When relevant to my claim(s) or request(s) RCMS is authorized to re-disclose any and all of my individually identifiable medical or health information(whether obtained pursuant to this authorization or otherwise from any person or entity) to any of the following: (a) Any person or facility that attends, treats or examines me; (b) Any person or facility that impacts determination of my claim or that coordinates my benefits; (c) My employer and its affiliates and their representatives, agents, independent contractors, insurers, benefit administrators and service providers that may receive any such information from my employer to the extent permitted by state or federal law.
2.How long is this Authorization Valid?
If I do not revoke this authorization in the manner set forth below, this authorization will be valid for 24 months from the date I sign this form or during the duration of my claim(s) or request(s), whichever is shorter.
3.Revocation of this Authorization.
Unless otherwise provided by federal or state law, I understand that I may revoke this authorization at any time by notifying RCMS in writing at: RCMS/PO Box 541686/Grand Prairie, TX 75054; Fax: 682-200-7472; email: email@example.com of my revocation and that my revocation shall be effective as to RCMS upon RCMS’ receipt of my notice of revocation. I also understand that my revocation of this Authorization will not have any effect on any actions taken by RCMS before receipt of my revocation.
4.Refusal to Sign:
I further understand that RCMS will not condition my treatment, care, enrollment or eligibility for service(s) on my refusal to sign this authorization.