Navigating the complexities of healthcare information can be a daunting task, particularly when it involves the sharing of personal health records or sensitive information. The HCA 80 020 form serves as a crucial instrument in this intricate process, granting authorized individuals or organizations access to specific health records under the governance of the Health Care Authority. This comprehensive document covers several pivotal areas including the personal details of the individual whose information is to be shared, the recipient of the information, and the specific type of health information that can be disclosed, which notably encompasses sensitive areas such as mental health and substance abuse treatment records. Furthermore, the form lays out critical aspects such as the conditions under which the information may be utilized, stipulations surrounding the release of particularly sensitive health information, and the rights of the individuals involved, including the ability to revoke the authorization and the protections against compulsory disclosure for healthcare benefits. Additionally, it outlines the protocols for the submission of the form depending on the enrollee’s health program, ensuring that the process remains as streamlined as possible for all parties involved. With its carefully delineated provisions and safeguards, the HCA 80 020 form embodies a significant tool in the management and disclosure of health information, balancing the need for information sharing with the imperative of individual privacy and consent.
| Question | Answer |
|---|---|
| Form Name | Form Hca 80 020 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | PEBB, enrollment, hca 80 020, Washington |
AUTHORIZATION FOR RELEASE OF INFORMATION
SECTION 1: Health Care Authority is authorized to provide information or records regarding:
Name:
Last name |
First name |
Middle initial |
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Address: |
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Phone (with area code): |
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Fax (with area code): |
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If this Release is for information pertaining to your dependent child(ren), name of dependent child(ren):
Person or organization authorized to receive information or records:
Name:
Address:
Phone:
I am enrolled in (Please check one box):
Basic Health |
Medical Assistance/SCHIP/MCS |
Public Employees Benefits Board (PEBB) Program |
Washington Health Program
Client I.D. Number or social security number:
Specific information to be used or disclosed (including dates if needed):
The following types of information must be specifically authorized. This authorization includes information about the following (check any that apply):
Sexually transmitted disease
HIV/AIDS and STD test results, diagnosis, or treatment
Mental health
Chemical dependency treatment
Reason for disclosure/purpose of disclosure:
This authorization will expire in 180 days or on:
Date or event
NOTICE to those receiving information: If these records contain information about HIV, STDs, or drug or alcohol abuse, you may not further disclose that information under federal and state law without specific permission of the subject and meeting specific legal requirements.
SECTION 2: Important Information About Your Rights
I have read and understand the following statements about my rights:
•I may cancel this authorization at any time prior to the expiration date or event noted above by telling the Health Care Authority in writing. The cancellation will not affect any information either received or given by the Health Care Authority before the cancellation notice was received.
•I may see and copy the information described on this form if I ask for it.
•I am not required to sign this form to receive health care benefits, such as enrollment, treatment, or payment. If I do not sign this form, the Health Care Authority may not release my information to any person or organization except those needed to determine my continued coverage, eligibility, and enrollment, or as allowed by law.
•The person or organization that I authorize to receive information about me or my dependent child(ren) might share it with another person or organization, and it might be not protected under the laws that apply to HCA.
•The Health Care Authority’s Privacy Notice is available upon request by calling
SECTION 3: Signature
Signature of enrollee or enrollee’s representative |
Date |
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Form must be completed before signing. |
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Printed name of enrollee’s representative |
Relationship to enrollee |
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Please return completed form to:
If Basic Health
If
If PEBB
If
HCA