Fillable Authorization to Use or Disclose Protected Health Information

Fill Online, Printable, Fillable, Blank Authorization to Use or Disclose Protected Health Information Form

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

Authorization to Use or Disclose Protected Health Information

On average this form takes 11 minutes to complete

The Authorization to Use or Disclose Protected Health Information form is 2 pages long and contains:

  • 2 signatures
  • 6 check-boxes
  • 33 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS 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
 
Page 1 of 2 Go to Next Page
Authorization to Use or Disclose Protected Health Information (PHI)
Consent to Release Protected Health Information
This form gives Magellan Rx permission to use or disclose protected health information to another person or entity.
Protected Health Information (PHI) means information about your health. Federal and State laws protect the
privacy of your PHI. The laws say we cannot give anyone other than your medical and pharmacy providers or
Magellan Rx Management (Magellan Rx) your PHI unless you say it is okay. By signing this form, you give us your
approval. We will only give out the PHI that you say we can share. We will only give it to the people or agencies
that you list.
It is important that all fields with an asterisk (*) are filled in with correct information. If not, this form will not be
accepted. Do you have questions? We can help. Call Magellan Rx at 1-800-424-3312.
*Check one:
I am the member.
– OR –
I have the legal right to act for this person. Check one of the below; if “other” fill in the blank:
I am his/her:
Guardian
Attorney
Power of Attorney
(* Provide supporting documentation of authorization to sign on behalf of the member)
SECTION 1 – WHO IS THE MEMBER?
*Last Name:
*First Name:
Middle Initial:
*ID Number/MBI:
Phone Number:
*Street Address (IF APPLICABLE AND ALLOWED BY LAW):
*City:
*ZIP Code:
SECTION 2 – WHO CAN GIVE OUT THE PHI?
By signing this form, you give Magellan Rx the approval to share your PHI. Magellan Rx manages your pharmacy
benefits.
SECTION 3 – TO WHOM CAN THE PHI BE GIVEN?
*Name (A PERSON OR AN ORGANIZATION):
Phone Number (IF KNOWN):
Street Address (IF KNOWN):
City:
State:
ZIP Code:
SECTION 4 – WHAT PHI CAN WE SHARE?
*Tell us exactly the information from your health records that we can share with the person/organization that you
named above:
We will only share the PHI that you approve. Please be specific. Examples are: medication name, dates of
services, pharmacy name, names of medical providers, medical condition, etc. A request to share “Everything”
will not be approved.
SECTION 5 – WHY DO YOU WANT US TO SHARE YOUR PHI?
*Tell us why you want us to share your PHI. You can just say “at the member’s request.”
At the member’s request – OR –
Reason you want us to share your PHI:
SECTION 6 – WHEN DOES THIS APPROVAL END?
Your approval will end when you tell us it does.
*Check One:
My approval ends on / / (It cannot be more than one year from your approval) - OR --
My approval ends when this happens:
It can be something like “You can share my pharmaceutical records this one time.”
Other:
*State:
Page 2 of 2
If you do not tell us when your approval ends, then your approval will end one year from when you sign this form.
After one year, we will need a new form completed.
SECTION 7 – YOUR RIGHTS AND IMPORTANT FACTS
▪ You do not have to provide your approval to share your information. Giving your approval is up to you. You
will still get benefits and treatment.
▪ You may revoke your approval at any time by writing to the address in Section 10 below.
▪ If you revoke your approval, it will not take back the PHI that we have already shared. But, we will not share
any more of your PHI.
▪ If we share your PHI with the people or agencies that you named, they may share it with others. Not everyone
has to follow privacy rules.
▪ You have a right to get a copy of this signed form. If you need another copy call Magellan Rx by referring to the
number on your ID card or by calling 1-800-424-3312.
▪ If you do not understand or if you have questions, we can help. Call Magellan Rx by referring to the number on
your ID card or by calling 1-800-424-3312.
*
A SIGNATURE AND DATE ARE REQUIRED IN EITHER SECTION 8 OR 9 BELOW
SECTION 8 – MEMBER SIGNATURE
Required if the member is completing this form. I give my approval to share the information listed on this form.
Signature:
Date:
OR
SECTION 9 – SIGNATURE OF PERSON LEGALLY AUTHORIZED TO SIGN FOR MEMBER
(i.e. Power of Attorney, etc.)
Required if the authorized representative is completing this form. Authorized Representative means that you have
legal proof that you can act for the member. A representative signs for a person who cannot legally sign on his/her own.
I give my approval to share the information listed on this form.
Printed Name:
Phone Number:
Street Address:
City:
State:
ZIP Code:
Signature:
Date:
SECTION 10 - WHERE DO I SEND THIS FORM?
Please return completed and signed authorization form to Magellan Rx Management. If you have questions about how
to complete this form, please contact us at any of the below.
Mailing Address: Phone/Fax E-mail Address:
Magellan Rx Management
Attn: Member Services
4801 E Washington Street
Phoenix, AZ 85034
Phone: 800-424-3312
Fax: 800-424-3260
ERxResponseTeam@magellanhealth.com
Notice to Recipient of Information
This information has been disclosed to you from records the confidentiality of which may be protected by federal and/or state law. If the
records are protected under the federal regulations on the confidentiality of alcohol and drug abuse patient records (42 CFR Part 2), you
are prohibited from making any further disclosure of this information unless further disclosure is expressly permitted by the written
consent of the person to whom it pertains, or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical
or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or
prosecute any alcohol or drug abuse patient.
* The Magellan Rx Management business division includes the following entities and their subsidiaries: Magellan Rx Medicare, Magellan
Rx Pharmacy, LLC, Magellan Method, LLC, Magellan Rx Management, Inc., Magellan Pharmacy Solutions, Inc., Magellan Medicaid
Administration, Inc., Magellan Administrative Services, Inc., 4-D Pharmacy, and Veridicus Holding, LLC.
Last Updated 10/01/2018
Reset Form
Print Form
click to sign
signature
click to edit
click to sign
signature
click to edit
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

Authorization to Use or Disclose Protected Health Information

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 31 May 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document