Get Member Authorization To Release Phi Forms - Molina Healthcare

Filling out the Member Authorization To Release Protected Health Information (PHI) Forms for Molina Healthcare is an important step in managing your healthcare information. This guide provides clear and supportive instructions to help users navigate the process effectively and efficiently online.

Follow the steps to complete the form easily and accurately.

1. Press the ‘Get Form’ button to obtain the Member Authorization To Release PHI Form and open it in the editor.
2. Fill in the 'Member Name' field with the full name of the person whose PHI is being authorized for release.
3. Enter the 'Member ID #' in the designated field to identify the member accurately.
4. Complete the 'Member Address' section including the full address where the member resides.
5. Input the 'Date of Birth' in the provided format, ensuring accuracy to confirm the identity.
6. Specify 'City', 'State', and 'Zip' where the member is located to complete their address.
7. Provide a phone number in the 'Phone #' section for contact purposes.
8. List the name and address of the Molina entity authorized to disclose the PHI as follows: Molina Healthcare of New Mexico, PO Box 3887, Albuquerque, NM 87190.
9. In the next field, include the name and address of the person or organization authorized to receive or use the PHI.
10. Describe the specific PHI that may be used and/or disclosed. Ensure to check if it includes sensitive information such as sexually transmitted diseases, HIV/AIDS, or mental health information.
11. State the purpose for which the PHI will be used and/or disclosed.
12. Read and acknowledge the voluntary nature of the authorization, confirming understanding that you do not have to sign the form.
13. Indicate the expiration date or event for the authorization, noting that it will expire 12 months from the date below if not specified.
14. Sign the form where indicated to authorize the use or disclosure of your PHI, and include the date of signature.
15. If applicable, print the name of the personal representative and describe their relationship to the member.
16. If the signer is a legal guardian or holder of power of attorney, attach any required legal documentation.
17. Once completed, review the entire form for accuracy, then save changes, download, print, or share the form as necessary.

Complete your Member Authorization To Release PHI Forms online today and ensure your healthcare information is managed effectively.