Fillable Authorization for Disclosure of Protected Health Information (PHI)

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Authorization for Disclosure of Protected Health Information (PHI)

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The Authorization for Disclosure of Protected Health Information (PHI) form is 2 pages long and contains:

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REV-7/2016 GB-05
Authorization for Disclosure of Protected Health Information (PHI)
Plan Member
Name:
Plan Member
Number: Date of Birth: / /
Address:
City: State: Zip Code:
I hereby authorize the Office of Group Benefits (OGB) to disclose the information described
below, verbally or in writing, to the person or entity identified below. This authorization
will remain in effect until revoked or as otherwise provided herein.
Plan Participant(s) for whom OGB is authorized to disclose:
Name:
Date of Birth: / /
Name:
Date of Birth: / /
Name:
Date of Birth: / /
Name:
Date of Birth: / /
Individual/Entity Authorized to Receive and Use Information:
Name:
Relation
to Member:
Address:
City: State: Zip Code:
Specific Description of information to be disclosed:
Specific Purpose of Disclosure:
At the request of the health Plan Member who is the subject of the information
At the request of OGB, for the following reason:
Other (Specify):
This authorization will expire: ____/____/____
REV-7/2016 GB-05
Authorization for Disclosure of Protected Health Information (PHI)
(Continued)
I understand that this authorization is voluntary.
Initials:
I understand that my health care and the payment for my health care will not be affected if I do not
sign this form, and that OGB will not condition payment, enrollment, or eligibility on whether I sign
this authorization.
Initials:
I acknowledge the potential for information disclosed pursuant to this authorization to be subject
to re-disclosure by the recipient and no longer protected under federal privacy regulations.
Initials:
I agree that a photographic copy of this authorization is as valid as the original. I
nitials:
I understand that I may see and copy the information described on this form if I ask for it, and that I
am entitled
to a copy of this form after I sign it.
Initials:
I understand that I may revoke this authorization at any time by notifying the Office of Group
Benefits in writing, but that if I do so the revocation will not have any effect on actions OGB took
before the revocation was received.
Initials:
/ /
Signature of Plan Member Date
(Or His/Her Representative)
If this form is signed by a personal representative, complete the following:
Printed Name of Plan Member’s Representative
Relationship to Plan Member
(Including authority to act as personal representative.)
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Authorization for Disclosure of Protected Health Information (PHI)

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Completed 16 July 2021

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