NJ_H0913_HIPAA_Auth_Form_122162_2024_R

Sep 17, 2026

Upload by Liam

Authorization to Use and Disclose Health Information for Wellcare Dual Liberty (HMO D-SNP), addressed to the Enrollment Department. The form explains that signing allows Wellcare Dual Liberty to use and/or share the member’s health information for a stated purpose and with named individuals or entities, while also noting the right not to provide permission and the ability to revoke by written request. It collects member identity details, recipient information, scope of released information (all versus specific categories), an end date or one-year default, and member or legal representative signatures.

LanguageEnglish

CategoryForms

FormatPDF

Pages3

Reading Time1 min

AccessFree to download

Authorization to Use and Disclose Health Information

Member Information

Purpose of Authorization

Person or Group to Receive Information

Type of Health Information to Release

Authorization Expiration

Signature and Legal Representative Information

Authorization to Use and Disclose Health Information Attn: Enrollment Department-CCP Wellcare Dual Liberty (HMO D-SNP) PO Box 31378 Tampa FL 33631 Fax: 1-866-473-9124 Notice to Member: • Completing this form will allow Wellcare Dual Liberty (HMO D-SNP) 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. • You do not have to give permission to use or share your health information. Your services and benefts with Wellcare Dual Liberty (HMO D-SNP) will not change if you do not submit this form. • 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. • Wellcare Dual Liberty (HMO D-SNP) cannot promise that the person or group you allow us to share your health information with will not share it with someone else. • Keep a copy of all completed forms that you send to us. We can send you copies if you need them. • If you need help, contact Member Services at the phone number on the back of your member ID card. • Fill in all the information on this form. When fnished, mail the form and any supporting documentation to: Attn: Enrollment Department-CCP Wellcare Dual Liberty (HMO D-SNP) PO Box 31378 Tampa FL 33631 Fax: 1-866-473-9124 H0913 _WCM_122162E_C Internal Approved 12092024 NJ3JMRFRM22162E_0000 Please read the instructions carefully and complete the form below. Incomplete forms cannot be accepted. 1 Member Information: Member Name (print): Member Date of Birth: Member ID Number: 2 I give Wellcare Dual Liberty (HMO D-SNP) 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): 􀂆 to allow Wellcare Dual Liberty (HMO D-SNP) to help me with my benefits and services, OR 􀂆 to permit Wellcare Dual Liberty (HMO D-SNP) to use or share my health information for 3 Person or group to receive information (add more persons or groups on next page): Name (person or group): Address: City: State: Zip: Phone: ( ) - 4 I authorize Wellcare Dual Liberty (HMO D-SNP) 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.) 􀂆 All of my health information INCLUDING: Genetic information, services, or test results; HIV/AIDS data and records; mental health data and records (but not psychotherapy notes); prescription drug/medication data and records; and drug and alcohol data and records (please specify any substance use disorder information that may be disclosed); OR 􀂆 All of my health information EXCEPT (check only the boxes below that apply): 􀂆 Genetic information, services, or tests 􀂆 Mental health data and records (but not 􀂆 AIDS or HIV data and records psychotherapy notes) 􀂆 Drug and alcohol data and records 􀂆 Prescription drug/medication data and records 􀂆 Other: 5 This authorization ends on this date/event: Date this authorization ends unless cancelled. If this field is blank, the authorization expires one year from the date of the signature below. 6 Member or Legal Representative Signature: Date: If Legal Representative-Relationship to Member: If you are the Member’s legal or personal representative, you must send us copies of relevant forms, such as power of attorney or order of guardianship. MAIL COMPLETED AUTHORIZATION FORM AND ANY SUPPORTING DOCUMENTATION TO Attn: Enrollment Department-CCP Wellcare Dual Liberty (HMO D-SNP) PO Box 31378, Tampa FL 33631 Fax: 1-866-473-9124 Additional individual person(s) or group(s) to receive inform

FAQs

What does signing this HIPAA authorization allow Wellcare Dual Liberty (HMO D-SNP) to do?

Completing the form permits Wellcare Dual Liberty to use your health information for a particular purpose and/or share it with the person or entity you identify on the form.

Is permission required to receive services and benefits from Wellcare Dual Liberty (HMO D-SNP)?

No. Your services and benefits will not change if you do not submit this form.

How can the authorization be revoked and when does it expire?

To cancel, send a written request to revoke it using the address on the bottom of the page. If the end date is blank, the authorization expires one year from the signature date.

Sep 17, 2026

Upload by Liam