Authorization to Disclose Protected Health Information (PHI)
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- Janis Strickland
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1 Authorization to Disclose Protected Health Information (PHI) Notice to Member: Completing this form will allow Trillium Medicare Advantage to share your health information with the person or group that you identify below. Your services and benefits with Trillium Medicare Advantage will not change if you do not sign this form. You do not have to give your health plan permission to share your health information. Trillium Medicare Advantage cannot promise that the person or group you want to share your health information with will not share it with someone else. You may revoke this authorization in writing by submitting the Revocation of Authorization form to Trillium Medicare Advantage at the address listed on the form in accordance with Trillium Medicare Advantage s Notice of Privacy Practices. You have a right to receive a copy of this authorization. A copy is as valid as the original. Fill in all the information on this form. When finished, mail it to the address at the bottom of the page. Member information: Member name (print): Member date of birth: / / Member ID number: I give Trillium Medicare Advantage permission to share my health information with the person or group (recipient) named below. The purpose of the authorization is to help me with Trillium Medicare Advantage benefits and services. Recipient information: Name (person or group): Address: City: State: ZIP: Phone: ( ) - Authorization Signed Date (if known): / / Trillium Medicare Advantage can share this Health Information: (check all boxes that apply) All of my PHI; OR All of my PHI EXCEPT: Prescription drug/medication information Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV) information Treatment for alcohol and/or substance abuse information Behavioral health services or psychiatric care information Other: ALL_18_2373FORM
2 Purpose: I authorize Trillium Medicare Advantage to disclose the information identified above for the following purpose(s): At my request Other (please specify): Authorization End Date: / / (If no date is provided, this authorization will expire in one year.) By signing the authorization, I acknowledge that I have read and understand the above information and that my signature authorizes the disclosure of the information described above. Member signature: Date: / / (Member or Legal Representative sign here) If you are signing for the Member, describe your relationship below. If you are the Member s personal representative, describe this below and send us copies of those forms (such as power of attorney or order of guardianship). Mail Completed Form To: Trillium Medicare Advantage Attn: Privacy Officer PO BOX 10420, Van Nuys, CA Phone: or TTY: 711 From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. Trillium Medicare Advantage is contracted with Medicare for HMO and HMO SNP plans, and with the Oregon Medicaid program. Enrollment in Trillium Medicare Advantage depends on contract renewal. FRM014785EO00 (8/17)
3 Trillium Medicare Advantage complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Trillium Medicare Advantage does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Trillium Medicare Advantage: Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact Trillium Medicare Advantage s Member Services at: (HMO SNP) (TTY: 711). From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. If you believe that Trillium Medicare Advantage has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; Trillium Medicare Advantage s Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, (TDD: ). Complaint forms are available at
4 Health Net complies with ATENCIÓN: applicable federal si habla civil español, rights laws tiene and a does su disposición not discriminate servicios on the gratuitos basis of de SPANISH asistencia lingüística. Llame al (HMO SNP) (TTY: 711). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho VIETNAMESE bạn. Gọi số (HMO SNP) (TTY: 711). 注意 : 如果您說中文, 您可以免費獲得語言援助服務 請致電 CHINESE (HMO SNP) (TTY: 711) RUSSIAN ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (HMO SNP) (TTY: 711). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수 KOREAN 있습니다 (HMO SNP) (TTY: 711) 번으로전화해주십시오. УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до UKRAINIAN безкоштовної служби мовної підтримки. Телефонуйте за номером (HMO SNP) (TTY: 711). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけ JAPANESE ます (HMO SNP) (TTY: 711) まで お電話にてご連絡ください تنبيھ: إذا كنت تتحدث العربية فإن خدمات المساعدة اللغوية المجانية متاحة لك. ي رجى االتصال بالرقم. ARABIC SNP) (HMO (مكبالو مصال فتاھ مقر: 711). ROMANIAN MON-KHMER CAMBODIAN ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la (HMO SNP) (TTY: 711). ច ណ ប អ រមមណ ប ស នអនកន យ យភ ស ខមរ សវ ជ ន យភ ស ដ យឥតគ ត ថល គ ម នស រ ប អនក ស មទ រស ពទ ទ លខ (HMO SNP) (TTY: 711) CUSHITE GERMAN PERSIAN FRENCH THAI XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa (HMO SNP) (TTY: 711).. ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (HMO SNP) (TTY: 711). توجھ : اگر بھ زبان فارسی گفتگو می کنيد تسھيالت زبانی بصورت رايگان برای شما فراھم می باشد. با (711 (TTY: (HMO SNP) تماس بگيريد. ATTENTION : Si vous parlez français, des services d aide linguistique vous sont proposes gratuitement. Appelez le (HMO SNP) (TTY: 711). เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร : (HMO SNP) (TTY: 711).
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