Get Consent To Release Health Information - Ccbh.com

Filling out the Consent To Release Health Information form is an essential step in ensuring your healthcare providers can communicate effectively about your health. This guide will provide you with clear and supportive instructions on how to complete the form online, facilitating coordinated care among your healthcare providers.

Follow the steps to complete your Consent To Release Health Information form online.

1. Click the ‘Get Form’ button to obtain the form and access it in your preferred format.
2. Begin by filling out Part 1, Member Information. Provide your last name, first name, middle initial, medical assistance ID number (MAID#), date of birth in MM/DD/YYYY format, phone number, and your complete address including city, state, and zip code.
3. In Part 2, indicate who your health information can be shared with by entering the organization’s name, phone number, and address. A staff member will require a signature here, along with the date of completion.
4. Complete the sections that allow sharing with your primary care provider, behavioral health provider, and any additional healthcare providers. For each, provide the provider's name, phone number, and address.
5. Select the appropriate physical health or behavioral health managed care organizations with which you consent to share your information. Provide the name of any other organization if applicable.
6. In Part 3, clarify the purpose of sharing this health information, emphasizing the benefits of coordinated healthcare planning.
7. Specify what type of health information can be shared in Part 4, making sure to note any substance use or HIV-related information that requires additional consent through Addendums A and B.
8. Review your understanding of the terms in Part 5. After reading, sign the form to give your consent, noting that this is voluntary and will remain valid for two years unless revoked.
9. If applicable, have your authorized representative sign the form in Part 7, ensuring to indicate their relationship and provide their contact information.
10. If necessary, fill out Part 8 for verbal consent if the member is physically unable to sign. This requires the signatures of two responsible witnesses.
11. Finally, save your changes, download the completed form, print it, or share it as needed with the appropriate health care providers.

Begin filling out your Consent To Release Health Information form online today to ensure your health information is shared as needed.