Get Authorization To Disclose Phi And Handle Carecentrix Accounts

This guide provides clear and comprehensive instructions on completing the Authorization To Disclose Protected Health Information (PHI) and Handle CareCentrix Accounts form online. By following these steps, you can effectively manage your health information while ensuring your privacy rights are respected.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the form and open it in a digital editor. This will allow you to fill in the required fields online.
2. Begin by providing your personal details. Enter your name, address, and date of birth in the designated fields marked with an asterisk. This information is essential for identifying your PHI.
3. Next, fill out your insurer's details. This includes your insurer's name, phone number, and ID number, as well as your CareCentrix Account Number. Ensure all fields with an asterisk are complete.
4. In the section for the individual or entity to whom the PHI is to be disclosed, provide the name and address of the authorized person. Again, include their date of birth and phone number, and specify their relationship to you.
5. Review the consent statement indicating that your PHI may be disclosed through various communication methods. Acknowledge your agreement by checking the appropriate boxes.
6. If applicable, indicate any specific information that should not be disclosed, such as HIV, mental health, or substance abuse information.
7. Sign and date the form in the designated sections, ensuring that your printed name is clearly noted. If someone else is signing on your behalf, include their relationship and attach any necessary authorization documentation.
8. Once all fields are completed, save your changes. You can then choose to download, print, or share the completed form as needed.

Take control of your health information by filling out the Authorization To Disclose PHI And Handle CareCentrix Accounts form online today.