Get Umha Member Consent & Authorization To Release Of Protected Health Information (phi)

Filling out the UMHA Member Consent & Authorization To Release Of Protected Health Information (PHI) online allows you to grant permission for the University of Maryland Medical System Health Plans to use and share your protected health information. This guide provides detailed instructions to help you complete each section of the form effectively.

Follow the steps to complete your consent form online.

1. Click the ‘Get Form’ button to obtain the Member Consent & Authorization To Release Of Protected Health Information (PHI) form and open it in your preferred online editor.
2. Carefully read the introduction section of the form. This section explains your rights under the Health Insurance Portability and Accountability Act (HIPAA) and outlines the entities that may disclose your information.
3. In Section 1, fill in your member information. Provide your last name, first name, member ID number, birth date, street address, city, state, ZIP code, and daytime telephone number. Indicate which health plan you are enrolled in by checking the appropriate box.
4. Section 2 requires you to appoint individuals who will receive your protected health information. Enter the name, daytime telephone number, street address, city, state, ZIP code, and their relationship to you for each individual you wish to authorize.
5. In Section 3, review the acknowledgment statement. By signing, you confirm your understanding of the information that may be disclosed and your rights regarding the consent.
6. Sign and date the form in Section 4. If you are signing on behalf of a minor, check the appropriate boxes indicating your relationship and confirm which conditions apply for the minor to sign.
7. Once all the fields have been completed accurately, you have options to save your changes, download a copy, print it out, or share the form as needed.

Complete your UMHA Member Consent & Authorization To Release Of Protected Health Information (PHI) form online today.