Get Member Release Of Information Form (pdf) - Valueoptions

Filling out the Member Release Of Information Form is an essential step for individuals seeking to authorize the disclosure of their health care information. This guide provides you with clear, step-by-step instructions to ensure you complete the form accurately and effectively.

Follow the steps to fill out the Member Release Of Information Form online:

1. Press the ‘Get Form’ button to obtain the form and open it in your PDF editor.
2. In Section 1, identify the person whose information is being released. Fill in their name, Member ID number, date of birth (DOB), and phone number.
3. Proceed to Section 2 and specify the individual or entity receiving the information. Provide their full name, contact information, and the reason for the disclosure, which can be as simple as 'at my request.' Include the phone number of the person receiving the records.
4. In Section 3, indicate what health information may be released. Choose either 'All Health Information' or 'Other' and describe any limitations you wish to impose by specifying providers, date spans, or service types. Additionally, initial any specific types of information you authorize to release, such as HIV/AIDS related information or mental health records.
5. Section 4 allows you to identify the duration of this authorization. Indicate if the authorization will last for one year, until revoked, or specify an expiration date or event.
6. Review Section 5 to understand your rights regarding the authorization. You can request copies of this form and any information disclosed, and you can revoke this authorization at any time by sending written notice.
7. Finish by signing the form in the designated area, providing the date, and printing your name. If signing as a legally authorized representative, remember to attach the necessary legal documents.
8. Save your changes, and consider downloading, printing, or sharing the completed form as needed.

Complete your Member Release Of Information Form online today for the smooth management of your health information.