HIPAA AUTHORIZATION TO DISCLOSE HEALTH INFORMATION

(Protected Health Information includes an individual’s health information that relates to their past, present or future physical or mental health and provision and payment of health care to an individual.)

I give permission for any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility or other healthcare provider that has provided payment, treatment or services to me or on my behalf and/or their business associates to give out protected health information (PHI) pertaining to me or any of my dependents listed below. The information that may be requested by Care Advocates for the purpose of assisting me with questions, obtaining health care services and approval or payment for health care services includes enrollment, claims payment, medical records and/or managed care information.