AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION
By completing this document, you authorize the disclosure and/or use of your individually identifiable health
information, as set forth below, consistent with Federal law concerning the privacy of such information.
Failure to provide all information may invalidate this Authorization.
ID Number: ___________________________________________ Date of Birth: ________________
I, __________________________________________ (your name), authorize Johns Hopkins Advantage
MD (HMO) and Johns Hopkins Advantage MD (PPO) to disclose my health information.
Person/Organization I authorize to receive my health information:
City, State and Zip: __________________________________________________________________
Phone Number: _____________________________________________________________________
What relationship is this person to you? ___________________________________________________
This Authorization applies to All Health Information including health (e.g., diagnosis, providers, treatments,
drugs), eligibility, enrollment and financial information (e.g., medical claims, premium bills, copayments),
substance abuse, mental health, HIV, etc.
As required by the Health Information Portability and Accountability Act if 1996, you have a right to nominate
one or more persons to act on your behalf with respect to your protected health information (PHI). Your
Personal Representative is given all of the privileges that you have with respect to your PHI. Your Personal
Representative may receive your PHI and also has the authority to modify your Johns Hopkins Advantage MD
health plan account (e.g., update your address change your Primary Care Physician). A personal representative
may be a spouse, relative, domestic partner or friend.
You are not required to have a Personal Representative, but if you want to designate someone who can
receive your PHI and modify your Johns Hopkins Advantage MD health plan account, please complete the
information below and attach appropriate documentation authorizing the representation (e.g., Power of
The person named below (same as individual named in Section 1) is to also be given all of the
privileges that would be given to me regarding my protected health information.
Personal Representative Name: _________________________________________________________
(Individual named in Section 1)
1. USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
2. DESIGNATION OF PERSONAL REPRESENTATIVE