Get I Understand That I May Inspect Or Request Copies Of Any Information Disclosed By This

Filling out the 'I Understand That I May Inspect Or Request Copies Of Any Information Disclosed By This' form is an important step in managing your health information. This guide will help you understand the process clearly and ensure you complete the form accurately.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and access it for completion.
2. In the 'Personal Information' section, enter the Medicaid recipient’s name, date of birth, and Medicaid ID number. This information is vital for identifying the individual whose health information is being disclosed.
3. Provide the social security number of the Medicaid recipient. This will assist in verifying their identity as needed.
4. In the section indicating who can access the health information, list the name of the law firm or law office, along with the name of the insurance company, and add any other entities as applicable.
5. Indicate the purpose of the information disclosure by checking the appropriate box. Options may include substantiation for a Medicaid lien or claims against an estate.
6. Specify the information you wish to be disclosed by checking one of the provided options, ensuring clarity on what health information you are authorizing to be shared.
7. Enter a specific expiration date for the authorization. This indicates how long the permission for disclosure will be valid.
8. Sign the form in the designated area. If a legal representative is signing, they must print their name, state their relationship to the Medicaid recipient, and provide their signature.
9. If applicable, include any required documentation that supports the legal authority of the representative. This could be a power of attorney or other relevant legal documents.
10. After completing the form, save any changes made, then download, print, or share the completed document as needed.

Complete your documents online today for efficient management of your health information.