Get Authorization To Disclose Health Information Form - Ambetter From ...

Filling out the Authorization To Disclose Health Information Form is an important step in allowing Ambetter from Coordinated Care to share your health information. This guide will walk you through the process step-by-step, ensuring that you complete the form accurately and efficiently.

Follow the steps to fill out the form effectively.

1. Click ‘Get Form’ button to access the form and open it for editing.
2. Begin by entering your member information. Fill in your name in the designated 'Member Name' field, your date of birth, and your member ID number. Ensure that all details are accurate and legibly written.
3. Next, indicate the recipient's information. Provide the name of the person or group to whom you wish to disclose your health information. Then, fill in the recipient's address, including city, state, and zip code. A phone number for the recipient is also required.
4. Select what health information you wish to share. You can check all applicable boxes to indicate whether you are allowing all of your protected health information (PHI) to be shared, or if you want to exclude specific information such as prescription details or substance abuse treatment.
5. Fill out the authorization end date. This date indicates when the permission to share your information will expire unless you choose to cancel it earlier.
6. Sign and date the form in the member signature section. If you are signing on behalf of the member, please include your relationship to the member and attach any necessary documentation, such as a power of attorney.
7. Once you have completed the form, review it for any errors or omissions. Ensure that all fields are filled out clearly and completely.
8. Finally, after reviewing your information, save any changes you have made, then download, print, or share the form. Make sure to keep a copy for your records, and mail the completed form to the address provided.

Complete the Authorization To Disclose Health Information Form online today to enable sharing of your vital health information.