Get Ny Emblemhealth Authorization To Use Or Disclose Protected Health Information 2021-2025

The NY EmblemHealth Authorization To Use Or Disclose Protected Health Information form is essential for individuals wanting to share their health information with designated people or organizations. This guide will provide clear instructions on how to complete this form online, ensuring that your health information is shared accurately and securely.

Follow the steps to fill out the form online:

1. Press the ‘Get Form’ button to obtain the NY EmblemHealth Authorization Form and open it in your preferred editor.
2. In the member information section, provide your member ID number, full name, mailing address, phone number (if you choose), and date of birth.
3. In the recipient information section, indicate the person(s) or organization(s) with whom you authorize EmblemHealth to share your information. Include their name, address, phone number (if applicable), and your relationship to them.
4. Fill out the purpose of the authorization field. You may select 'at my request' or specify another purpose for sharing your information.
5. In the information to be disclosed section, decide if you want to share 'all' clinical, claims, billing, benefit, or coverage information, or if you will list specific information to be shared. Remember, sensitive information requires your initials to authorize.
6. Indicate the term of authorization. You can either specify an end date or describe an event that will terminate this authorization. If not specified, it will remain valid for 24 months.
7. Read the conditions of authorization carefully to understand the potential implications of sharing your information.
8. Sign the form, either as the member or through an authorized personal representative. Ensure to attach documentation if acting on behalf of someone else.
9. Once you have completed all sections of the form, you can save your changes, download it, print it, or share it as needed.

Complete your NY EmblemHealth Authorization Form online today.