Fillable 0G 08/05/19 AUTHORIZATION FOR USE OR DISCLOSURE OF (GEHA)

Fill Online, Printable, Fillable, Blank 0G 08/05/19 AUTHORIZATION FOR USE OR DISCLOSURE OF (GEHA) Form

Use Fill to complete blank online GEHA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

0G 08/05/19 AUTHORIZATION FOR USE OR DISCLOSURE OF (GEHA)

On average this form takes 8 minutes to complete

The 0G 08/05/19 AUTHORIZATION FOR USE OR DISCLOSURE OF (GEHA) form is 2 pages long and contains:

  • 1 signature
  • 9 check-boxes
  • 25 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your GEHA forms online.

BROWSE GEHA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
08/05/19
PHI07/R13
ENR-1485-PHI07
GE-FRM-0119-005
0G
AUTHORIZATION FOR USE OR DISCLOSURE OF
PROTECTED HEALTH INFORMATION (“PHI”)
Use this form to give GEHA permission to discuss your PHI with the authorized person(s) listed
below.
About you, the GEHA member whose PHI may be used or disclosed
Plan ID Number:
Member Name: Date of Birth: _______________________
Address:
Telephone Number:
Please place a check mark in front of each plan you want this Authorization to be applied:
___ GEHA Health Plan ___GEHA Connection Dental Federal Plan
___ Connection Dental Plus Plan ___CONNECTION Vision Plan
Authorized Use and / or Disclosure
I hereby authorize the Government Employees Health Association, Inc. (GEHA) to (choose one or both as appropriate):
___use or disclose my PHI as indicated below TO:
___obtain my PHI FROM:
Authorized Person #1:
Name: Phone Number:
Address:
Relationship to You:
Authorized Person #2:
Name: Phone Number:
Address:
Relationship to You:
Purpose of Disclosure: _______________________________________________________(reason can be
“personal”)
08/05/19
PHI07/R13
ENR-1485-PHI07
GE-FRM-0119-005
Information To Be Used or Disclosed
I authorize the use or disclosure of the following PHI (check the applicable box(es) below):
___ All of my health information maintained by or on behalf of GEHA, including any mental health, drug/alcohol abuse,
or communicable disease treatment records that may be maintained by GEHA.
___Only the following records or types of health information: _______
___LIMIT disclosure to healthcare services provided between the dates: ____/____/____ to ____/____ /____
Term of Authorization
This authorization will expire one year from the date it is signed, unless I specify a date or event of expiration:
______________________________________________ (expiration date or event). If I terminate from GEHA
coverage, I understand this Authorization will terminate automatically.
Important Information About Your Rights
By signing this form, I understand and agree:
• This authorization is voluntary and I may refuse to sign it.
• I may revoke this authorization at any time by notifying GEHA in writing to the address provided on this form.
I further understand the revocation will not have any effect on any actions GEHA took before it received the
revocation notice.
• I am not required to sign this authorization as a condition to receiving treatment or payment for health care;
enrolling in a health plan; or establishing eligibility for benefits.
• The information that is used or disclosed pursuant to this authorization may be redisclosed by the receiving
person or organization and, upon redisclosure, no longer be protected by federal privacy laws.
• My health information may contain information created by other persons or entities including health care
providers and may contain medical, pharmacy, dental, vision, mental health, substance abuse, HIV/AIDS,
psychotherapy, reproductive, communicable disease and health care program information.
• GEHA and GEHA’s business associates may disclose my PHI as outlined to the person(s) named for the
purpose(s) described above.
• I have had full opportunity to read and consider the content of this Authorization Form.
Signature and Acknowledgement
By signing below, I acknowledge that I have read and understand this Authorization.
Date:
Patient or Legal Representative Signature:
Relationship to patient:
(i.e. parent, legal guardian, power of attorney, etc.)
NOTE: If the signature is not that of the member or the parent when the child is a minor, appropriate legal
documentation is required to accept the signature.
click to sign
signature
click to edit
08/05/19
PHI07/R13
ENR-1485-PHI07
GE-FRM-0119-005
Y
OU ARE ENTITLED TO A COPY OF THIS AUTHORIZATION FORM AFTER YOU SIGN IT.
P
LEASE RETAIN A COPY FOR YOUR RECORDS AND RETURN THE ORIGINAL SIGNED AUTHORIZATION FORM TO:
ATTN: Authorization
GEHA
P.O. Box 21542
Eagan, MN 55121
FAX: 816-257-3283
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

0G 080519 AUTHORIZATION FOR USE OR DISCLOSURE OF (GEHA)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 21 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document