Provident Claims Services, Inc.

PO Box 38295

Pittsburgh, PA 15238-8295

Toll-Free: 800.478.1752 | Fax: 412.963.0148

claims@providentclaims.com

Business Hours: 8:30 AM to 5 PM

Please note, this document could take up to 15+ minutes to complete. If you wish to start filling it out now, you can always press "Save & Continue Later" at the bottom of this form to complete and submit at a later time. 

THIS FORM IS ONLY ACCEPTABLE FOR USE WHEN APPLYING FOR MENTAL STRESS MANAGEMENT BENEFITS

I CERTIFY THAT THE ABOVE ANSWERS ARE TRUE AND COMPLETE ACCORDING TO THE BEST OF MY KNOWLEDGE AND BELIEF.

I hereby authorize any physician, hospital, insurer, governmental agency, other organization or person having any records, data or other information concerning me to furnish such records, data or information as may be requested by Provident or its duly authorized representative. I understand that in executing this authorization I waive the right for such information to be privileged. A copy of this authorization shall be considered as effective and valid as the original.

THE AUTHORIZATION INCLUDED WITH THIS FORM MUST BE SIGNED AND RETURNED TO PROVIDENT CLAIMS SERVICES, INC.

See Important Notice Regarding Fraud in the PDF at the beginning of this form. 

Failure to complete this form in its entirety may result in a delay of processing your claim. 

Please sign and submit this authorization to Provident Claims Services, Inc. (PCS). You are entitled to receive a copy of this authorization. This authorization is designed to comply with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.

Authorization to Disclose Psychotherapy Notes

I authorize ______________________________________ (print name of health care provider) (“Provider”);

To disclose Psychotherapy Notes;

To the following persons: Provident for the purpose of evaluating and administering claims, includingassistance with return to work.

This authorization applies to medical records created by Provider and to any records that Provider receivedfrom any other source as long as the other source has not prohibited disclosure of those records.

“Psychotherapy Notes” means notes about me, recorded in any form, by a health care provider who is amental health professional; that document or analyze the contents of conversation during a private, group,joint or family counseling session; and, that are separate from the rest of my medical record. “PsychotherapyNotes” does not mean: medication prescription and monitoring; counseling session start and stop times; themodes and frequencies of treatment furnished; results of clinical tests; and, any summary of the followingitems: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

Information authorized for use or disclosure may include information which may indicate thepresence of a communicable or non-communicable disease.

If I do not sign this authorization or if I alter or revoke it, Provident may not be able to evaluate my claim(s),which may lead to my claim(s) being denied. I may revoke this authorization at any time by sending writtennotice to the address above. I understand that revocation will not apply to any information that is requestedprior to Provident receiving notice of revocation.

The privacy protections established by HIPAA may not apply to information disclosed under thisauthorization, but other privacy laws do apply. Information disclosed under this authorization may beredisclosed only as permitted or required by law, including state fraud reporting laws.

This authorization is valid for one (1) year from the date below, or the duration of my claim(s), whicheverperiod is shorter. A copy of this authorization is as valid as the original.

Parts 1 and 2 must be completed to properly identify the records to be released:

I understand that this Authorization is valid for a period of two (2) years from the date of the signature, or the duration of my claim, whichever is shorter. A photographic or electronic copy of this authorization is as valid as the original. I understand that I am entitled to receive a copy of this authorization. I understand that once this information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations. I understand that I have the right to revoke this authorization at any time by sending a written request to the entity/person I authorized above to release information.

**THE USE OF AN AUTHORIZED REPRESENTATIVE IS ONLY APPLICABLE IF THE MEMBER IS UNABLE TO SIGN ON THEIR OWN BEHALF.**

As an authorized representative, I have uploaded the documentation granting this authority. Please refer to POA, Guardianship, or Estate documentation. 

**ORAL AUTHORIZATION (for persons physically unable to sign)**

NOT Applicable to HIV related Information or Drug & Alcohol Treatment Information

I witness that the patient understood the nature of this release and freely gave their oral authorization. (Two witnesses are required)