AUTHORIZATION TO DISCLOSE SUBSTANCE USE TREATMENT INFORMATION FOR COORDINATION OF CARE

Section 1: Purpose of Authorization

This Authorization to disclose is for the purpose of permitting the Maryland Medical Assistance Program (the Medicaid program), my substance use treatment provider, and any other providers identified in this form for healthcare operations and payment purposes, including but not limited to care coordination, so that it is more beneficial to me. By giving my consent, my Medicaid Managed Care Organization and any other providers specifically identified on this form will have access to information about substance use treatment I am receiving, which will help avoid conflicts in medication or treatment and improve the care I am receiving. By giving this consent, I may also gain access to other case management services offered through the Medicaid program.

Section 2: Entities Authorized to Disclose My Substance Use Disorder Records

My Substance Use Disorder Provider(s), or if indicated, the provider listed below:

Section 3: Duration and Revocation of Authorization

This authorization will expire one year from the date I sign it. I may revoke this authorization at any time by notifying the Maryland Medicaid Program's Administrative Services Organization, Optum Maryland, either orally or in writing at the address below; however, the revocation will not have an effect on any actions taken prior to the date my revocation is received and processed. To revoke the authorization, notify Optum at:

Optum Maryland
PO BOX 30531
Salt Lake City, UT 84130

Phone: 800.888.1965 / Fax: 855-293-5407

Section 4: Authorization

I hereby authorize my substance use treatment provider(s) to disclose to the Maryland Medicaid Program (including its administrative services organization, Optum Maryland), claims and authorization data resulting from my treatment, for purposes of healthcare operations and payment purposes, not limited to coordination of my care If you want to identify the kind or amount of information that you are authorizing for disclosure, you may do so here:

I also authorize the Maryland Medicaid Program (including Optum Maryland) to re-disclose my claims and authorization data to the Medicaid Managed Care Organization (MCO) in which I am enrolled, and with any additional health care providers listed on this form below, for purposes of coordinating my health care.

I further authorize my substance use treatment provider(s) to disclose medical records requested by my MCO's patient care coordination team, for purposes of coordinating my care.

Section 5 (OPTIONAL): I authorize the Maryland Medicaid Program, Optum Maryland, my MCO, and my substance use disorder treatment provider(s) to disclose all substance use disorder treatment records to the additional health care provider(s) specified below for treatment purposes:

I understand that the information that may be disclosed as a result of this authorization may not be redisclosed to any other entity except those entities identified in this authorization.

I also understand that, for two years following the date of my signature, I have the right to find out who in the MCO actually saw my information.

I have been provided a copy of this Authorization.

 NOTE: If you are signing as the member's Legally Authorized Representative, attach a copy of the legal document(s) granting you the authority to do so. Examples are a health care power of attorney, a court order, guardianship papers, etc. The following are the Maryland Medicaid Managed Care Organizations (MCOs).

 

FAX completed form to Optum Maryland: 1-855-293-5407 or
Mail to: Optum Maryland, Attn: ROI
P.O. Box 30531
Salt Lake City, UT 84130

 

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