Get Authorization For A One-time Written Release Of Personal ... - Caremark

Filling out the Authorization For A One-time Written Release Of Personal Health Information form with Caremark can seem daunting. This guide provides clear instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the authorization form effectively.

1. Press the ‘Get Form’ button to access the form in your preferred editing tool.
2. Begin by entering the last name, first name, and middle initial of the plan participant in the designated fields. If applicable, include the previous last name as well.
3. Fill in the address, city, state, and zip code of the plan participant to ensure accurate identification.
4. Provide the date of birth in the specified format (mm/dd/yyyy) and include a valid phone number.
5. Input the CVS/caremark plan participant's primary cardholder identification number. This number is essential for identifying the individual in the system.
6. If the requestor is not the plan participant, enter their name and specify the relationship to the plan participant. If necessary, provide legal documentation as per the options.
7. Indicate which information you authorize to be released by selecting the appropriate checkboxes. Specify any additional health information, if necessary, and provide relevant dates.
8. Add the name and organization of the individual or entity receiving the information. If this is the same as the plan participant's address, utilize the checkbox provided.
9. State the purpose of the authorization request by marking the relevant option and providing further details if needed.
10. Sign and date the form to verify that all provided information is accurate. If signing on behalf of the plan participant, outline your legal authority and attach any supporting documentation.
11. Complete the witness signature section if required, including the witness name and date.
12. Submit the completed form by returning it to the address listed for CVS/caremark, ensuring that it reaches the correct department.

Complete your Authorization For A One-time Written Release Of Personal Health Information form online today.