Fillable AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION TO AHCCCS (Arizona Health Care Cost Containment System)

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AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION TO AHCCCS (Arizona Health Care Cost Containment System)

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DE-202(6/2020) 1
AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
TO AHCCCS
Return Information to:
AHCCCS
801 E. Jefferson St. MD 3900
Phoenix, AZ 85034
Fax: 602-253-6038
AHCCCS Worker Name:
Email:
Phone Number:
Customer Name:
Date of Birth:
AHCCCS ID Number or PID:
Date of Request:
Customer Address:
Social Security Number (SSN):
(SSN is optional but may help the provider
locate records)
For use by AHCCCS customers/applicants who want a doctor or other entity to
give AHCCCS their protected health information.
I give my permission for any health care provider to disclose any of my protected health information to
AHCCCS, for the purpose of determining my eligibility for any of the publicly-funded programs
administered by AHCCCS. I give AHCCCS permission to share this information with the Arizona
Department of Economic Security, Disability Determination Services Administration, if necessary, to
determine my disability status.
In addition, by checking these boxes, I specifically authorize the disclosure of the following types of
medical records:
HIV/AIDS and communicable disease related information and/or records
Mental health information and/or records
Genetic testing information and/or records
If the information to be disclosed comes from a school, please fill out this box:
I specifically authorize the holder of my information to disclose all of my educational and
evaluation records in its possession to AHCCCS.
DE-202(6/2020) 2
By signing this Authorization, I understand that:
AHCCCS is required by state and federal law to keep confidential the information described
above and may only use or disclose that information with my approval, for purposes directly
related to the administration of the AHCCCS program, or as otherwise permitted or required by
law.
I also understand that if I refuse to sign or revoke this authorization, AHCCCS may not be able
to determine my current or future eligibility for the publicly funded medical assistance programs
administered by AHCCCS. As a result, my application for assistance may be denied or the
assistance may be discontinued.
I may revoke this authorization, in writing, at any time, by completing an AHCCCS “Revocation
of Authorization” form, and sending it to:
Arizona Health Care Cost Containment System
Office of Legal Assistance
Attention: Privacy Officer
701 E. Jefferson, MD 6200
Phoenix, AZ 85034
Phone 602-417-4232
Fax 1-602-253-9115
Once AHCCCS receives the revocation, this authorization will be revoked, except to the extent that
AHCCCS has already taken action in reliance upon this authorization.
Please choose one of the following:
This authorization will expire on:
Insert specific date:
Insert specific event:
The customer's signature is required to get medical records. If the customer is under the age of
18, the signature of the customer's parent is needed. If the customer has a legal guardian or
legal representative, the signature of the legal guardian or legal representative is needed.
Signature:
Date:
Printed name of person signing form:
Relationship to Customer:
Printed name of witness (only needed if customer
signed with mark):
Signature of witness:
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AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION TO AHCCCS (Arizona Health Care Cost Containment System)

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Completed 12 August 2020

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