Get Umha Member Consent & Authorization To Release Of Protected Health Information (phi) 2016-2025

Filling out the UMHA Member Consent & Authorization To Release Of Protected Health Information form online is an important process for managing your health information. This guide will take you through each step clearly and effectively, ensuring that you understand how to complete the form accurately.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to access the form and open it in your digital editing tool.
2. Begin by providing your personal information in Section 1. Fill in your last name, first name, member ID number, birth date, street address, city, state, ZIP code, and daytime telephone number. Select your enrollment in either University of Maryland Health Partners or University of Maryland Health Advantage.
3. In Section 2, designate individuals authorized to receive your protected health information (PHI). Provide their names, daytime telephone numbers, street addresses, city, state, ZIP codes, and your relationship to each person.
4. Indicate the level of access each authorized individual will have by checking the appropriate boxes. You can choose from three categories: Appointment of Representative for Limited Actions, Appointment of Representative for Information Only, or Durable Power of Attorney/Legal Guardian/Other Legal Representative.
5. Review the statements in Section 3. By signing, you acknowledge that you understand the implications of disclosing your PHI and the terms of the release.
6. In Section 4, provide your signature, print your name, and specify your relationship to the member if you are not signing on your own behalf. Ensure that you check the applicable boxes regarding minors if relevant.
7. Once all sections are completed, save your changes. You may also download, print, or share the completed form as needed.

Complete your UMHA Member Consent & Authorization To Release Of Protected Health Information form online today to ensure your health information is managed effectively.