The person whose information is to be released: Name Member ID# DOB / / Phone Number SECTION 2: Identify the person or entity who is to receive the information and the reason for the disclosure (the reason for disclosure may be at my request ): Print the Name(s) of person receiving records, contact information, and reason for disclosure:.
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How to fill out the Value Options Form LC417A online
The Value Options Form LC417A is a crucial document that allows for the authorized disclosure of health care information. This guide offers a step-by-step approach to completing the form online, ensuring clarity and ease for all users.
Follow the steps to complete the Value Options Form LC417A effectively.
- Click ‘Get Form’ button to obtain the form and open it in your online editor.
- In Section 1, identify the person whose information is being released by entering their name, member ID, date of birth, and phone number. Ensure all details are accurate to avoid processing issues.
- In Section 2, specify the person or entity receiving the information. Provide their name, contact information, and the reason for the disclosure. You may choose ‘at my request’ if applicable.
- In Section 3, indicate what health information may be disclosed. Initial the boxes corresponding to the types of information you authorize to be released: mental health information, substance use information, HIV/AIDS-related information, or any other health information. If there are specific limitations, provide that information as well.
- In Section 4, indicate the length of time you want this authorization to remain in effect. You can choose for it to last for one year or specify another expiration date or event.
- In Section 5, review your rights regarding this authorization. Make sure to sign and date the form, and print your name under the signature line. If you are a legally authorized representative, attach the necessary legal document.
- Once all sections are completed, save your changes. You can then download, print, or share the completed form as needed.
Complete your Value Options Form LC417A online for efficient processing.
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What is the payer ID for Carelon behavioral health?
Search: Payer NamePayer ID CARELON BEHAVIORAL HEALTH BHOVO CAREMORE CM001 CAREMORE HEALTH PLAN (RH) RHCAM CAREOREGON, INC 93975240 more rows
How do I contact Carelon provider portal?
If you need assistance, please Click Here or contact Carelon Medical Benefits Management provider portal support at (800) 252-2021.
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