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The form requires completion of member and (if applicable) employee information, identification of authorized individuals/companies, and selection of the intended purpose(s) and PHI categories. It explains voluntary consent, limits on psychotherapy notes, recipient notice regarding further disclosure restrictions, validity for one year unless a shorter period is chosen, and consent implications for enrollment and benefit eligibility.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/authorization-for-release-of-protected-health-information-phi-member-level/288652/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/authorization-for-release-of-protected-health-information-phi-member-level/288652.png","ImageObject",442,249,{"name":88,"@type":89},"River Wang","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Is the PHI release authorization voluntary, and can it be denied?","Question",{"text":108,"@type":109},"The authorization is voluntary. If you do not sign, your request to release information to the named recipient(s) will not be honored, and eligibility/enrollment for a Meritain Health plan is not affected by whether you sign.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information can be authorized to be released, and is psychotherapy notes included?",{"text":113,"@type":109},"You can authorize only the PHI categories you checked. This authorization cannot be used to share psychotherapy notes, and it specifies categories such as health, disability, behavioral health (excluding psychotherapy notes), claims, and other details.",{"name":115,"@type":106,"acceptedAnswer":116},"How long is the authorization valid?",{"text":117,"@type":109},"This authorization is valid for 1 year from the date signed unless you indicate a shorter period in the date range fields.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288652,1789633747,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":125,"read_time":9},1099514067438,"https://ap-avatar.wpscdn.com/avatar/100002539ee87300030?x-image-process=image/resize,m_fixed,w_180,h_180&k=1780474512215547542","Authorization for Release of  \nProtected Health Information (PHI)  \nMy health record is private and is known under the law as “Protected Health Information (PHI)”.  \nBy completing and signing this form, I, or my legal representative, agree to allow Meritain Health and any of its parents, subsidiaries and affiliates, and their respective employees, agents and subcontractors, to share my PHI with the people or companies listed below.  \nI UNDERSTAND THAT THIS AUTHORIZATION IS VOLUNTARY.  \nPlease submit a separate Authorization for Release of Protected Health Information (PHI) for each plan member for whom Meritain Health is being requested to disclose PHI to a third party. If both sides of this form are not completed, as applicable, Meritain Health will be unable to process your request. Incomplete authorization requests will be returned.  \nPlease print all responses  \n\n| 1. Member Information |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| Last Name |  | First Name |  | Middle Initial |\n| ID Number | Group Number or Group Name | Birth Date (MM/DD/YYY) | Phone Number (Including Area Code) |  |\n| Street Address |  | City | State | Zip Code |\n\n\n| 2. Employee Information (Please complete this section if the employee is not the member whose records are being requested.) |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| Last Name |  | First Name |  | Middle Initial |\n| ID Number | Group Number or Group Name | Birth Date (MM/DD/YYY) | Phone Number (Including Area Code) |  |\n| Street Address |  | City | State | Zip Code |\n\n\n| 3. I authorize the individual(s) or company(ies) identified below to receive PHI pertaining to the member identified in Section 1 above.* |  |  |  |\n| --- | --- | --- | --- |\n| Individual or Company Authorized to Receive PHI |  | Phone Number (Including Area Code) |  |\n| Street Address | City | State | Zip Code |\n| Individual or Company Authorized to Receive PHI |  | Phone Number (Including Area Code) |  |\n| Street Address | City | State | Zip Code |\n| Individual or Company Authorized to Receive PHI |  | Phone Number (Including Area Code) |  |\n| Street Address | City | State | Zip Code |\n\n\n| 4. Purpose(s) for this Authorization |\n| --- |\n| I only want to share the PHI I have checked below. This authorization cannot be used to share psychotherapy notes. (Check all that are appropriate)\u003Cbr>􀂉 Any information requested 􀂉 Health (this includes medical, dental, pharmacy, vision, and flexible spending account information)\u003Cbr>􀂉 Disability 􀂉 Behavioral Health (e.g. mental health, drug and alcohol abuse treatment, but NOT psychotherapy notes)\u003Cbr>􀂉 Life Benefits 􀂉 Long term care\u003Cbr>􀂉 Patient management records 􀂉 Application or enrollment information\u003Cbr>􀂉 Claim status 􀂉 Claim records\u003Cbr>􀂉 Other (please explain)  \u003Cbr>This authorization will be valid for 1 year from the date signed, unless you indicate a shorter period below.\u003Cbr>   through  \u003Cbr>MM/DD/YYYY MM/DD/YYYY |\n\n1  \n31.5162017  \n*NOTICE TO RECIPIENT(S) OF INFORMATION (Section 3 on page 1):  \nInformation disclosed to you pertaining to certain conditions, such as treatment for alcohol or drug abuse, HIV/AIDS and other sexually transmitted diseases, behavioral health, and genetic marker information is protected by various federal and state laws which prohibit any further disclosure of this information by you without the express written consent of the person to whom it pertains or as otherwise permitted by such laws. Any unauthorized further disclosure in violation of state or federal law may result in a fine or jail sentence or both. A general authorization for the release of medical or other information is NOT sufficient consent for release of these types of information. The federal rule at 42 CFR Part 2 restricts use of the information disclosed to criminally investigate or prosecute any alcohol or drug abuse patient.  \n\n| 5. IMPORTANT: Your signature below means that you understand andagree tothe following |\n| --- |\n| 􀁸 My PHI that I agree to share may be sensitive. It may ","cbCaiuwMyvPe4VOj","https://ap.wps.com/l/cbCaiuwMyvPe4VOj","pdf",139471,"English","# Member Information\n## Employee Information\n## Authorized Recipient(s) and Information Purpose(s)\n## Important Notices\n## Signature of Member or Legal Representative","[{\"question\":\"Is the PHI release authorization voluntary, and can it be denied?\",\"answer\":\"The authorization is voluntary. If you do not sign, your request to release information to the named recipient(s) will not be honored, and eligibility/enrollment for a Meritain Health plan is not affected by whether you sign.\"},{\"question\":\"What information can be authorized to be released, and is psychotherapy notes included?\",\"answer\":\"You can authorize only the PHI categories you checked. This authorization cannot be used to share psychotherapy notes, and it specifies categories such as health, disability, behavioral health (excluding psychotherapy notes), claims, and other details.\"},{\"question\":\"How long is the authorization valid?\",\"answer\":\"This authorization is valid for 1 year from the date signed unless you indicate a shorter period in the date range fields.\"}]","Authorization for Release of Protected Health Information (PHI) - Member Level | PDF"]