Get De Authorization For Release Of Protected Health Information

The DE Authorization For Release Of Protected Health Information is essential for individuals to share their medical records with designated parties. This guide provides a straightforward approach to help users complete this form accurately and effectively.

Follow the steps to complete your authorization form online.

1. Press the ‘Get Form’ button to access the form and ensure it opens in a suitable editor to begin inputting your information.
2. In Section 1, provide the necessary details of the person whose health information will be disclosed. Include the name, address, city and state, health plan ID number (if applicable), group number (if applicable), telephone number, and birth date.
3. In Section 2, indicate the person or entity that possesses the health information to be released. This could be a specific health plan or a medical professional such as a doctor.
4. In Section 3, describe the health information you wish to disclose. Include relevant claim numbers and dates of service. If applicable, check the boxes for sensitive diagnoses like substance abuse or mental health care.
5. In Section 4, provide details about the person or entity receiving the health information. Include their name, relationship to the member, and a best contact telephone number.
6. For Section 5, explain the purpose of the health information release. This may include obtaining assistance with claim adjudication or support for non-health benefits.
7. In Section 6, specify the duration of the authorization. Choose either an expiration date, or state it will expire one year after the member's signature, unless otherwise indicated.
8. In Section 7, certify your authorization by signing the form, providing your daytime telephone number, and email address. If signing as a personal representative, include your name and authority.
9. Finally, submit the completed form to the Statewide Benefits Office using secure email, fax, or by mail. Ensure that you retain a copy of your signed authorization.

Take control of your health information and fill out your authorization form online today.