Release of Protected Health Information Authorization Form

Release of Protected Health Information Authorization Form
As required by the Health Insurance Portability and Accountability Act (HIPAA), Performance Health and its subsidiaries may not use or disclose your protected health information except as provided in our Notice of Privacy Practices. Your signature on this form indicates you are giving permission for Performance Health to provide your protected health information to the person or entity named below
Member's Name:*

First NameLast Name
Member ID:*
Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Do you want to designate any individual / entity to receive any health information?*

YESNO
Authorized Individual / entity*

Full Name

Relationship to Member

CityState / Province

Phone Number
Disclosure Option*

FULL DISCLOSURE: Any and all protected health information that Performance Health maintains, including but not limited to mental health, HIV, or substance abuse.LIMITED DISCLOSURE: Designate below what information to disclose
LIMITED DISCLOSURE: Information to be disclosed (Select all that apply)*

Personal Health / Diagnosis InformationClaim Payment InformationCoordination of BenefitsPrescription Drug InformationSpecific Dates of ServiceOther
Additional Authorized Individual / entity*

YESNO
Authorized Individual / entity*

Full Name

Relationship to Member

CityState / Province

Phone Number
Disclosure Option*

FULL DISCLOSURE: Any and all protected health information that Performance Health maintains, including but not limited to mental health, HIV, or substance abuse.LIMITED DISCLOSURE: Designate below what information to disclose
LIMITED DISCLOSURE: Information to be disclosed (Select all that apply)*

Personal Health / Diagnosis InformationClaim Payment InformationCoordination of BenefitsPrescription Drug InformationSpecific Dates of ServiceOther
Additional Authorized Individual / entity*

YESNO
Authorized Individual / entity*

Full Name

Relationship to Member

CityState / Province

Phone Number
Disclosure Option*

FULL DISCLOSURE: Any and all protected health information that Performance Health maintains, including but not limited to mental health, HIV, or substance abuse.LIMITED DISCLOSURE: Designate below what information to disclose
LIMITED DISCLOSURE: Information to be disclosed (Select all that apply)*

Personal Health / Diagnosis InformationClaim Payment InformationCoordination of BenefitsPrescription Drug InformationSpecific Dates of ServiceOther
Additional Authorized Individual / entity*

YESNO
Authorized Individual / entity*

Full Name

Relationship to Member

CityState / Province

Phone Number
Disclosure Option*

FULL DISCLOSURE: Any and all protected health information that Performance Health maintains, including but not limited to mental health, HIV, or substance abuse.LIMITED DISCLOSURE: Designate below what information to disclose
LIMITED DISCLOSURE: Information to be disclosed (Select all that apply)*

Personal Health / Diagnosis InformationClaim Payment InformationCoordination of BenefitsPrescription Drug InformationSpecific Dates of ServiceOther
Additional Authorized Individual / entity*

YESNO
Authorized Individual / entity*

Full Name

Relationship to Member

CityState / Province

Phone Number
Disclosure Option*

FULL DISCLOSURE: Any and all protected health information that Performance Health maintains, including but not limited to mental health, HIV, or substance abuse.LIMITED DISCLOSURE: Designate below what information to disclose
LIMITED DISCLOSURE: Information to be disclosed (Select all that apply)*

Personal Health / Diagnosis InformationClaim Payment InformationCoordination of BenefitsPrescription Drug InformationSpecific Dates of ServiceOther
Additional Authorized Individual / entity*

YESNO
Authorized Individual / entity*

Ful Name

Relationship to Member

CityState / Province

Phone Number
Disclosure Option*

FULL DISCLOSURE: Any and all protected health information that Performance Health maintains, including but not limited to mental health, HIV, or substance abuse.LIMITED DISCLOSURE: Designate below what information to disclose
LIMITED DISCLOSURE: Information to be disclosed (Select all that apply)*

Personal Health / Diagnosis InformationClaim Payment InformationCoordination of BenefitsPrescription Drug InformationSpecific Dates of ServiceOther
Specific Dates of Service that should not be disclosed
List all that apply
Authorization

I authorize the use or disclosure of my protected health information by Performance Health to the following individual(s) or entity.

This authorization will expire Date. If no expiration date or event is indicated, this authorization will expire when my enrollment with Performance Health ends. I also understand I may revoke this authorization at any time by providing Performance Health with written notice of revocation at the address listed below. If I so revoke this authorization, it will not have any effect on any information released before revocation, including any action taken by the individual or entity that received the protected health information. Protected health information used or disclosed as instructed by this authorization may be further disclosed by the individual or entity receiving the protected health information and, therefore, no longer protected by HIPAA.

I understand I am under no obligation to sign this authorization. I further understand my ability to obtain insurance or eligibility for benefits will not depend in any way on whether I sign this authorization.

A copy of this Authorization Form is available to me or to my Legal Representative upon request.
Print Name*
Date*

MonthDayYear
Date
Signature*

Clear
Performance Health

PO Box 450978 | Westlake, OH 44145 | 877-585-8480
Should be Empty: