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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The AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION TO AHCCCS (Arizona Health Care Cost Containment System) form is 5 pages long and contains:

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  • 16 other fields

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File type: PDF

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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:
Customer Address:
AHCCCS ID Number or PID:
Date of Request:
DE-202 Large Print form (06/2020)
2
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
DE-202 Large Print form (06/2020)
3
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.
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
DE-202 Large Print form (06/2020)
DE-202 Large Print form (06/2020) 4
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:
5
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:
DE-202 Large Print form (06/2020)
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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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