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The form collects member identity details, the receiving party’s contact information, and the stated reason for release, and it specifies which record categories may be shared, including required mental health, HIV/AIDS, and alcohol or substance use selections when applicable. 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It also allows sharing with family, providers, legal representatives, or anyone the member identifies.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What types of information may be released and how are they selected?",{"text":113,"@type":109},"The form specifies categories that can be released, including mental health information, alcohol or substance use information, HIV/AIDS related information, and other health information (with special instructions). Selection is done by initialing required items and completing optional sections on the following page.",{"name":115,"@type":106,"acceptedAnswer":116},"How long does the authorization last and what are the revocation rules?",{"text":117,"@type":109},"The authorization is effective for one year or until revocation, whichever is shorter, as described in the form. 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You may allow Carelon Behavioral Health to share health care information with your family, providers, legal representative, or anyone you wish to have access. Please fill in all sections as incomplete forms may be returned.  \nPlease note: It is also important for your doctor to have access to your medical information to ensure you receive the best care possible, including any follow-up care that may be needed. To allow Carelon Behavioral Health the ability to send your health care information to your doctor, complete and sign this form. We will only send information that pertains to your care.  \nIf your request involves alcohol or substance use information, please pay attention to the special instructions in the applicable sections.  \nSECTION 1: WHOSE HEALTH CARE INFORMATION IS TO BE RELEASED?  \nI,   (Member Name) authorize Carelon Behavioral Health (or any Carelon Behavioral Health subsidiary holding my information) to disclose my health care information as described below. Additional Member Identifying Information Member ID\\#:   DOB:  / /  Phone Number:   Name of Health Plan:    \nSECTION 2: WHO IS TO RECEIVE THIS HEALTH CARE INFORMATION?  \nPrint the Name(s) of person, provider or entity who will be receiving your information and contact information (if known):  \n_________________________________________________________________________________________________  \n_________________________________________________________________________________________________  \n_________________________________________________________________________________________________  \nPhone number of who will be receiving your information:   Is it ok to include information from past, present, and/or future treating provider(s)?: Yes No  \nSECTION 3: WHY SHOULD THIS HEALTH CARE INFORMATION BE RELEASED?  \nReason (“At my request” is an acceptable response):    \n_________________________________________________________________________________________________  \nSpecify, if possible: Care Coordination/Management Claim Assistance Quality of Care Review  \nOther (Please explain reason):    \nSECTION 4: WHAT HEALTH CARE INFORMATION MAY BE RELEASED?  \nBY INITIALING the items on the following page, you authorize Carelon Behavioral Health to release specific types of information to the party identified in Section 2 above:  \nPage 1 of 2 Learn more at: [carelonbehavioralhealth](carelonbehavioralhealth.com)[.com](carelonbehavioralhealth.com) Updated 3/17  \nAuthorization for Carelon Behavioral Health to Release Confidential Information  \n  Mental health information and/or records (INITIALS REQUIRED)  \n  Alcohol or substance use information and/or records (INITIALS REQUIRED)  \nOptional: 􀀀 Claims info 􀀀 Authorizations 􀀀 Explanation of benefit letters 􀀀 Denials/Appeals info 􀀀 Clinical notes  \n  HIV/AIDS related information and/or records (INITIALS REQUIRED)  \n  Other health information, please specify (INITIALS REQUIRED) :    \nSpecial instructions, if any (you may specify provider, date span, service type, etc. ):    \n_________________________________________________________________________________________________  \nSECTION 5: HOW LONG SHOULD THIS AUTHORIZATION LAST?  \nThis authorization shall be in force and effect for one year or until I revoke it, in the manner described below or until (insert expiration date or event)   (whichever is shorter) .  \nSECTION 6: WHAT ARE MY RIGHTS?  \n• You have a right to request a copy of this form and to request a copy of the information that is being disclosed.  \n• You do not have to sign this authorization and your refusal will not affect your benefits unless this authorization is necessary to determine your benefits.  \n• The information disclosed by this authorization may be at r","cbCail9IIESAOqzw","https://ap.wps.com/l/cbCail9IIESAOqzw","pdf",648415,"English","# SECTION 1: WHOSE HEALTH CARE INFORMATION IS TO BE RELEASED?\n# SECTION 2: WHO IS TO RECEIVE THIS HEALTH CARE INFORMATION?\n## CONTACT INFORMATION AND PREFERENCES\n# SECTION 3: WHY SHOULD THIS HEALTH CARE INFORMATION BE RELEASED?\n# SECTION 4: WHAT HEALTH CARE INFORMATION MAY BE RELEASED?\n## REQUIRED INITIALS AND OPTIONAL CATEGORIES\n# SECTION 5: HOW LONG SHOULD THIS AUTHORIZATION LAST?\n# SECTION 6: WHAT ARE MY RIGHTS?","[{\"question\":\"Who can receive the released health care information under this authorization?\",\"answer\":\"The form allows the member to name the person, provider, or entity that will receive the information, and it provides space for contact details (if known). It also allows sharing with family, providers, legal representatives, or anyone the member identifies.\"},{\"question\":\"What types of information may be released and how are they selected?\",\"answer\":\"The form specifies categories that can be released, including mental health information, alcohol or substance use information, HIV/AIDS related information, and other health information (with special instructions). Selection is done by initialing required items and completing optional sections on the following page.\"},{\"question\":\"How long does the authorization last and what are the revocation rules?\",\"answer\":\"The authorization is effective for one year or until revocation, whichever is shorter, as described in the form. Revocation can be requested, but the form explains that revocation does not affect information already sent, and verbal revocation is permitted only for alcohol or substance use treatment records; other record types require written revocation.\"}]","Authorization for Carelon Behavioral Health to Release Confidential Information - Release of Information Form | PDF"]