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It collects member identity details, the health plan entity, and the recipient contact information. The form requires selection of what information may be released, including special categories and required state-specific permissions, and includes an expiration section plus voluntary acknowledgment and signature areas for the member or personal representative.",{"@graph":63,"@context":119},[64,80,102],{"@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":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/authorization-to-release-information-please-print/283892/",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-release-information-please-print/283892.png","ImageObject",442,249,{"name":88,"@type":89},"Bulrr","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",7,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What is the purpose of this authorization form?","Question",{"text":109,"@type":110},"It authorizes a Health Plan to release protected health information to a person or organization the member chooses, as permitted by privacy laws.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What information must be completed about the member and the recipient?",{"text":114,"@type":110},"The form collects member identifying information (including ID, address, date of birth, and contact details) and requires the recipient’s name or organization and contact information.",{"name":116,"@type":107,"acceptedAnswer":117},"How does expiration work for this authorization?",{"text":118,"@type":110},"The authorization ends based on the checked option—revocation, a specified date/event/condition, or default timelines described for certain states—whichever is earliest.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},283892,1790187869,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},5909892115043,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","| Authorization to Release Information [Please Print] |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| This form is used to release your protected health information as required by federal and state privacy laws. Your authorization allows the Health Plan (your health insurance carrier or HMO) to release your protected health information to a person or organization that you choose. You can revoke this authorization at any time by submitting a request in writing to the Health Plan (contact Member Services for further instructions) . Revoking this authorization will not affect any action taken prior to receipt of your written request. |  |  |  |  |\n| Section A. Member Information: (individual whose information will be released) |  |  |  |  |\n| Name: (First, Middle, Last, Title) |  |  | Member ID Number: | Group Number: |\n| Address: (including zip code) |  |  | Telephone Number: (including area code) |  |\n| Date of Birth: (Month/Day/Year) |  |  |  |  |\n| Section B. Health Plan: (organization that will release your information) |  |  |  |  |\n| I authorize AmeriHealth Administrators to release my protected health information as described below. |  |  |  |  |\n| Section C. Recipient: (person or organization that will receive your information) |  |  |  |  |\n| Person’s Name or Organization: |  | Address: (including zip code) |  |  |\n| Telephone Number: (including area code) |  | Fax Number: (if available) |  |  |\n| Section D. Description of the Information to be Released: (what type of information will be released) |  |  |  |  |\n| Check ONLY ONE box:\u003Cbr>□ Psychotherapy notes – Federal law requires a separate authorization to use or release psychotherapy notes. \u003Cbr>If you check this box, you may not check another box below. \u003Cbr>□ All information related to the provision of and payment for my health care benefits or services.*\u003Cbr>□ Specific information as described on the line below:*\u003Cbr>Examples: The claim related to my service on (date); Appeal information related to my claim on (date)\u003Cbr>*NOTE: State law requires that you give specific permission to release the information below even if you checked a box above. Indicate your permission for the Health Plan to release any of the following information by initialing all that apply.\u003Cbr>Genetic Information   (Initials) HIV/AIDS   (Initials)\u003Cbr>Substance/Alcohol Abuse   (Initials) Mental/Behavioral Health   (Initials)\u003Cbr>Purpose of Release:  \u003Cbr>Examples: At my request; To resolve my appeal; To assist with my health insurance services |  |  |  |  |\n| Section E. Expiration: (when this authorization will end)** |  |  |  |  |\n| This authorization will expire (Check ONLY ONE box):\u003Cbr>□ When I revoke this authorization* □ Upon the following date, event or condition*:  Note: This authorization will terminate on the earliest of the events listed above or 180 days after termination of coverage.\u003Cbr>* The party identified in Section B must be notified in writing of the event/condition to cancel or revoke this authorization. ** Please note: State law requires that this Authorization to Release Information will automatically expire in 12 months for Minnesota residents and in 24 months for Montana residents unless you specify a shorter timeframe. |  |  |  |  |\n| \u003Cbr>Section F. Approval: (You OR your Personal Representative must sign and date this form in order for it to be complete.) |  |  |  |  |\n| I understand that this authorization to release information is voluntary and is not a condition of enrollment in this Health Plan, eligibility for benefits, or payment of claims. I also understand that if the person or organization I authorize to receive the information described above is not subject to federal health information privacy laws, they may further release the protected health information and it may no longer be protected by federal privacy laws. |  |  |  |  |\n| Member Signature: By signing below, I authorize the release of my protected health information as described above. | Personal Representativ","cbCaiqPHQM7aasV9","https://ap.wps.com/l/cbCaiqPHQM7aasV9","pdf",67536,"English","# Section A. Member Information\n# Section B. Health Plan\n# Section C. Recipient\n# Section D. Description of the Information to be Released\n# Section E. Expiration\n# Section F. Approval","[{\"question\":\"What is the purpose of this authorization form?\",\"answer\":\"It authorizes a Health Plan to release protected health information to a person or organization the member chooses, as permitted by privacy laws.\"},{\"question\":\"What information must be completed about the member and the recipient?\",\"answer\":\"The form collects member identifying information (including ID, address, date of birth, and contact details) and requires the recipient’s name or organization and contact information.\"},{\"question\":\"How does expiration work for this authorization?\",\"answer\":\"The authorization ends based on the checked option—revocation, a specified date/event/condition, or default timelines described for certain states—whichever is earliest.\"}]","Authorization to Release Information - Please Print | PDF",1789621518]