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Includes sections to identify the member or guardian, contact and mailing details, and the effective time period for the authorization. States the right to revoke permission, how to withdraw by mail/email/fax, and that prior good-faith actions remain unaffected. Identifies who may receive and use the health information and lists categories of information that may be disclosed with required initials, followed by HIPAA-related statements and compliance notes.",{"@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-to-disclose-protected-health-information-hipaa-release-form/288400/",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-to-disclose-protected-health-information-hipaa-release-form/288400.png","ImageObject",442,249,{"name":88,"@type":89},"Aria Callaghan","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who is allowed to complete and request the disclosure of PHI on this form?","Question",{"text":108,"@type":109},"The form can be completed by a member (over 18) requesting disclosure. It can also be completed by a parent/guardian for members under 18, and the guardian must include proof of identity and legal rights.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How does the authorization period work and how long is it valid?",{"text":113,"@type":109},"The authorization provides options such as a one-year period from the signed date or an end date selected on the form. The effective time period must be completed for the authorization to be valid.",{"name":115,"@type":106,"acceptedAnswer":116},"How can the signer revoke the authorization?",{"text":117,"@type":109},"The signer may withdraw permission at any time by sending Community a letter via mail, email, or fax to the address at the end of the document. The letter must include the member’s full name, member number, address, and phone number.","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},288400,1790195060,{"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":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"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":139,"read_time":9},962084926284,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","page 1/3  \nAUTHORIZATION TO DISCLOSE  \nPROTECTED HEALTH INFORMATION  \nThis authorization is voluntary and may be used to permit Community Health Choice (Community) to use or disclose an individual’s protected health information (PHI) .  \nIndividuals completing this form should read the form in its entirety before signing and complete all the sections that apply to their decisions relating to the use or disclosure of their PHI.  \n As a member (over 18 years of age) of Community, I am requesting disclosure of PHI to the individual as  \nrequested below.  \n As a parent/guardian of a member (under 18 years of age) of Community, I am requesting disclosure of PHI as requested below, and have included proof of identity and legal rights.  \nMEMBER FULL NAME  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nMEMBER ID NUMBER MEMBER DATE OF BIRTH  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nMAILING ADDRESS  \n\n|  |  |\n| --- | --- |\n\n/  \n\n|  |  |\n| --- | --- |\n\n/  \n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nCITY  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nDAY PHONE  \n\n|  |  |  |\n| --- | --- | --- |\n\n/  \n\n|  |  |  |\n| --- | --- | --- |\n\n/  \n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\nE-MAIL ADDRESS  \nZIP CODE  \n\n|  |  |  |  |  |\n| --- | --- | --- | --- | --- |\n\nOTHER PHONE  \n\n|  |  |  |\n| --- | --- | --- |\n\n/  \n\n|  |  |  |\n| --- | --- | --- |\n\n/  \n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nEFFECTIVE TIME PERIOD: Please choose and complete one.  \nThis authorization is valid for a  \nperiod of one year from the date signed:  \nThis authorization shall only be valid until:  \nRIGHT TO REVOKE:  \nMonth  \nMonth  \nDay  \nDay  \nYear  \nYear  \n\n|  |  |  |  |\n| --- | --- | --- | --- |\n|  |  |  |  |\n|  |  |  |  |\n\nI understand that I can withdraw my permission at any time by sending Community a letter via mail, email or fax, to the address listed at the end of this document. Your letter must also include the member’s full name, member number, address, and phone number.  \nThe authorization will have no effect on actions Community took in good faith before receiving a letter to withdraw authorization.  \n[CommunityCares.com](CommunityCares.com)  \nfm_phirelease_0117  \npage 2/3  \nWHO CAN RECEIVE AND USE THE HEALTH INFORMATION?  \nNAME  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nMAILING ADDRESS  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nCITY  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nDAY PHONE  \n\n|  |  |  |\n| --- | --- | --- |\n\n/  \n\n|  |  |  |\n| --- | --- | --- |\n\n/  \n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\nZIP CODE  \n\n|  |  |  |  |  |\n| --- | --- | --- | -","cbCaipo6UPo4zhuo","https://ap.wps.com/l/cbCaipo6UPo4zhuo","pdf",129450,"English","# Authorization to Disclose Protected Health Information\n## Member or Guardian Request and Identity Fields\n## Effective Time Period and Right to Revoke\n## Who Can Receive and Use the Health Information\n## What Information Can Be Disclosed\n## HIPAA Statement","[{\"question\":\"Who is allowed to complete and request the disclosure of PHI on this form?\",\"answer\":\"The form can be completed by a member (over 18) requesting disclosure. It can also be completed by a parent/guardian for members under 18, and the guardian must include proof of identity and legal rights.\"},{\"question\":\"How does the authorization period work and how long is it valid?\",\"answer\":\"The authorization provides options such as a one-year period from the signed date or an end date selected on the form. The effective time period must be completed for the authorization to be valid.\"},{\"question\":\"How can the signer revoke the authorization?\",\"answer\":\"The signer may withdraw permission at any time by sending Community a letter via mail, email, or fax to the address at the end of the document. The letter must include the member’s full name, member number, address, and phone number.\"}]","AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION - HIPAA Release Form | PDF",1789633447]