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It clarifies voluntary consent, effects of not submitting, and how to revoke the authorization by written request. Instructions emphasize completing all required fields, maintaining copies, selecting which categories of health information may be disclosed, and noting when the authorization ends. 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Ben White Blvd. Austin, TX 78741  \nNotice to Member:  \n􀁸 Completing this form will allow Superior HealthPlan to (i) use your health information for a particular purpose, and/or (ii) share your health information with the individual or entity that you identify on this form.  \n􀁸 You do not have to give permission to use or share your health information. Your services and benefits with Superior will not change if you do not submit this form.  \n􀁸 If you want to cancel this authorization form, send us a written request to revoke it at the address on the bottom of this page. A revocation form can be provided to you by calling Member Services at the phone number on the back of your member ID card.  \n􀁸 Superior cannot promise that the person or group you allow us to share your health information with will not share it with someone else.  \n􀁸 Keep a copy of all completed forms that you send to us. We can send you copies if you need them.  \n􀁸 If you need help, contact Member Services at the phone number on the back of your member ID card.  \n􀁸 Fill in all the information on this form. When finished, mail the form and any supporting documentation to  \nSuperior HealthPlan  \nATTN: Compliance Department  \n5900 E. Ben White Blvd.  \nAustin, TX 78741  \nAviso para el afiliado:  \n􀁸 Al completar este formulario, le permitirá a Superior HealthPlan (i) utilizar su información de salud para un propósito específico y/o (ii) compartir su información de salud con la persona o entidad que identifique aquí .  \n􀁸 No tiene obligación de autorizar que se utilice o comparta su información de salud. Si no envía este formulario, los servicios y beneficios que recibe de Superior no cambiarán.  \n􀁸 Si desea cancelar este formulario de autorización, envíenos una solicitud por escrito para revocarlo a la dirección que aparece en la parte inferior de esta página. Si quiere que le proporcionemos un formulario derevocación, llame a los Servicios para afiliados al número telefónico que aparece en la parte posterior de su tarjeta de identificación de afiliado.  \n􀁸 Superior no puede prometer que la persona o el grupo con el que nos permite compartir su información de salud no la compartirá con alguien más.  \n􀁸 Mantenga una copia de todos los formularios completados que usted nos envía. Podemos enviarle copias silas necesita.  \n􀁸 Si necesita ayuda, llame a los Servicios para afiliados al número telefónico que aparece en la parte posterior de su tarjeta de identificación de afiliado.  \n􀁸 Complete toda la información en este formulario. Cuando termine, envíe por correo postal el formulario y la documentación de apoyo, si la hubiera, a la siguiente dirección:  \nSuperior HealthPlan  \nATTN: Compliance Department  \n5900 E. Ben White Blvd.  \nAustin, TX 78741  \nSHP_20184729  \nPLEASE READ THE INSTRUCTIONS CAREFULLY AND COMPLETE THE FORM BELOW. INCOMPLETE FORMS CANNOT BE ACCEPTED.  \nMEMBER INFORMATION:  \nMember Name (print):   Member Date of Birth:   Member ID Number:    \nI GIVE SUPERIOR HEALTHPLAN PERMISSION TO USE MY HEALTH INFORMATION FOR THE PURPOSE IDENTIFIED OR TO SHARE MY HEALTH INFORMATION WITH THE PERSON OR GROUP NAMED BELOW. THE PURPOSE OF THE AUTHORIZATION IS (check one option below):  \n□ to allow Superior to help me with my benefits and services, OR  \n□ to permit Superior to use or share my health information for    \nPERSON OR GROUP TO RECEIVE INFORMATION (add more Persons or Groups on next page):  \nName (person or group):   Address:   City:   State:   Zip:   Phone: (   )   -    \nI AUTHORIZE SUPERIOR TO USE OR SHARE THE FOLLOWING HEALTH INFORMATION (NOTE: Select the first statement to release ALL health information or select the below statement to release only SOME health information. Both CANNOT be selected.)  \n□ All of my health information INCLUDING:  \nGenetic information, services or test results; HIV/AIDS data and records; mental health data and records (but not psychotherapy notes); prescription drug/med","cbCain1mpCZSRWn9","https://ap.wps.com/l/cbCain1mpCZSRWn9","pdf",606724,"English","# Notice to Member\n# Member Authorization Choices\n## Purpose of Authorization\n## Person or Group to Receive Information\n# Health Information to Be Used or Shared\n## All Health Information\n## All Except Selected Categories\n# Authorization End Date and Signatures\n# Mailing Instructions","[{\"question\":\"What does completing this authorization form allow Superior HealthPlan to do?\",\"answer\":\"It allows Superior HealthPlan to use the member’s health information for a specified purpose and/or share it with the person or entity identified on the form.\"},{\"question\":\"Do I have to sign or submit this form for my services and benefits to continue?\",\"answer\":\"No. Services and benefits with Superior HealthPlan do not change if you do not submit this form.\"},{\"question\":\"How can I cancel or revoke the authorization?\",\"answer\":\"Send a written request to revoke it to the address shown at the bottom of the page. A revocation form can be provided by calling Member Services using the phone number on the back of the member ID card.\"}]","Authorization to Use and Disclose Health Information - Authorization Form | PDF",1789633449]