Authorization to Disclose Protected Health Information (PHI)

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Transcription:

Authorization to Disclose Protected Health Information (PHI) Notice to Member: Completing this form will allow Health Net to share your health information with the person or group that you identify below. Your services and benefits with Health Net 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. Health Net 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 Health Net at the address listed on the form in accordance with Health Net 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 Health Net permission to share my health information with the person or group (recipient) named below. The purpose of the authorization is to help me with Health Net benefits and services. Recipient information: Name (person or group): Address: City: State: ZIP: Phone: ( ) - Authorization Signed Date (if known): / / Health Net 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 06242017

Purpose: I authorize Health Net 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: Health Net Attn: Privacy Officer, PO Box 10420 Van Nuys, CA 91410-0420 Phone: California: 1-800-977-6738; Oregon: 1-800-949-6192 or TTY: 711 From October 1 through February 14, our office hours are 8:00 a.m. to 8:00 p.m., 7 days a week, excluding certain holidays. However, after February 14, our office hours are 8:00 a.m. to 8:00 p.m., Monday through Friday. On weekends and certain holidays, your call will be handled by our automated phone system. TTY users should call 711. FRM014175EO00 (7/17)

Health Net complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Net does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Health Net: 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 Health Net s Customer Contact Center at California: 1-800-431-9007 (Jade, Sapphire, Amber, and HMO SNP), 1-800-275-4737 (all other HMO); Oregon: 1-888-445-8913 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 Health Net 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; Health Net s Customer Contact Center 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 https://ocrportal.hhs.gov/ocr/portal/lobby.jsf 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, 1-800-368-1019 (TDD: 1-800-537-7697). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ARABIC 1-800-275-4737 (all other HMO); Oregon: 1-888-445-8913 (HMO and PPO) ARMENIAN 1-800-275-4737 (all other HMO) (TTY: 711). CHINESE 1-800-275-4737 (all other HMO); Oregon: 1-888-445-8913 (HMO and PPO) (TTY: 711) CUSHITE (TTY: 711). Oregon: 1-888-445-8913 (HMO and PPO) FRENCH (TTY: 711). Oregon: 1-888-445-8913 (HMO and PPO) GERMAN Oregon: 1-888-445-8913 HINDI 1-800-275-4737 (all other HMO) (TTY: 711). HMONG California: 1-800-431-9007 (Jade, Sapphire, Amber, and HMO SNP), 1-800-275-4737 (all other HMO) (TTY: 711). JAPANESE KOREAN 1-800-275-4737 (all other HMO); Oregon: 1-888-445-8913 (HMO and PPO) (TTY: 711)

MON-KHMER CAMBODIAN 1-800-275-4737 (all other HMO); Oregon: 1-888-445-8913 (HMO and PPO) (TTY: 711) PERSIAN PUNJABI California: 1-800-431-9007 (Jade, Sapphire, Amber, and HMO SNP), 1-800-275-4737 (all other HMO) (TTY: 711) ROMANIAN Oregon: 1-888-445-8913 RUSSIAN California: 1-800-431-9007 (Jade, Sapphire, Amber, and HMO SNP), 1-800-275-4737 (all other HMO); Oregon: 1-888-445-8913 SPANISH California: 1-800-431-9007 (Jade, Sapphire, Amber, and HMO SNP), 1-800-275-4737 (all other HMO); Oregon: 1-888-445-8913 (HMO and PPO) (TTY: 711). TAGALOG THAI California: 1-800-431-9007 (Jade, Sapphire, Amber, and HMO SNP), 1-800-275-4737 (all other HMO) (TTY: 711). California: 1-800-431-9007 (Jade, Sapphire, Amber, and HMO SNP), 1-800-275-4737 (all other HMO); Oregon: 1-888-445-8913 UKRAINIAN Oregon: 1-888-445-8913 VIETNAMESE

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