Get Form 1.3: Authorization Cancellation - Prime Therapeutics

Filling out the Form 1.3: Authorization Cancellation is an essential step if you wish to cancel a previously authorized release of your information to Prime Therapeutics. This guide will provide you with clear instructions to assist you in completing the form accurately and efficiently.

Follow the steps to complete the Authorization Cancellation form

1. Click the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Fill in the name, member identification, and date of birth of the person whose Authorization is on file. Ensure this information is accurate to avoid any delays.
3. Select the types of information you would like Prime Therapeutics to stop releasing by checking the appropriate boxes. Options may include Benefits, Claims, Psychotherapy notes, and Premium information.
4. Provide the name and address of the person or group you want to prevent from accessing your information. This ensures that only authorized entities can view your data.
5. If you are signing on behalf of the member, complete the Personal Representative section of the form and attach documentation of your legal authority, such as a Power of Attorney.
6. Sign and date the form to validate your cancellation request. Keep a copy of this signed notice for your records.
7. Finally, mail or fax the completed form to the designated address or number provided: Prime Therapeutics LLC, Attention: Privacy Officer, P.O. Box 64812, St. Paul, MN 55164-0812, Fax: 866-470-8807.

Take the first step towards managing your information by completing the Form 1.3 online today.