Form Hca 80 020 – Fill Out and Use This PDF

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
Address:
Phone (with area code):			Fax (with area code):

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):

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 360-923-2822 (effective January 1, 2012, call 360-725-0442) or online at www.hca.wa.gov.

SECTION 3: Signature

Signature of enrollee or enrollee’s representative	Date
Form must be completed before signing.
Printed name of enrollee’s representative	Relationship to enrollee

Please return completed form to:

If Basic Health member—Health Care Authority, P.O. Box 42683, Olympia, WA 98504-2683

If Medicaid—Health Care Authority, P.O. Box 45509, Olympia WA 98504-5509, fax to 360-586-9323

If PEBB member—Health Care Authority, P.O. Box 42684, Olympia, WA 98504-2684 or fax to 360-923-2608 (effective January 1, 2012, fax to 360-586-2288) If Washington Health Program member—Health Care Authority, PO Box 42714, Olympia, WA 98504-2714

If Subrogation—Health Care Authority, P.O. Box 45561, Olympia WA 98504-5561

HCA 80-020 (11/11)