Understanding the complexities of healthcare information sharing, especially in the context of personal accidents and the coverage provided by MassHealth, requires navigating specific procedures and policies. The MassHealth Casualty Recovery form plays a crucial role in this process, facilitating the sharing of sensitive information between the Casualty Recovery Unit members and designated recipients like family members, legal representatives, or healthcare advocates. This form is a vital instrument for individuals who need to authorize the release of their medical claims to third parties, particularly in situations related to accident claims or legal representation. It outlines precise instructions on where and how to submit the form, the type of information that can be shared (including sensitive drug and alcohol treatment data), and who can receive this information. It also emphasizes the importance of accurately providing contact details to ensure the correct sharing of information. Furthermore, the form provides an option for the requester to specify a termination date for the authorization, beyond the default 18-month period, reinforcing the individual’s control over their personal information. Additionally, through completing this form, individuals are made aware that once information is shared, it could potentially be redistributed by the recipient under fewer protections, a critical consideration for privacy. Lastly, it is essential to recognize that this form harbors no implications for the continuation of MassHealth benefits, thereby relieving the individual from concerns about the potential impact of their request on future healthcare coverage.
| Question | Answer |
|---|---|
| Form Name | Masshealth Casualty Recovery Form |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | masshealth casualty recovery, ma casualty recovery unit, ma casualty insurance prep, printable mass health pso form |
MASSHEALTH/CASUALTY RECOVERY UNIT
PERMISSION TO SHARE INFORMATION (PSI) FORM
When to use this form:
Use this form if you want the Casualty Recovery Unit to share the information we have about you with another person or organization, such as:
O a family member, friend, or other relative; O an attorney representing you,
O a social worker, lawyer, or
Where to send this form:
If you are authorizing the sharing of only medical claims information send the PSI to:
Commonwealth of Massachusetts
Casualty Recovery Unit
P. O. Box 15205
Worcester, MA
OR
Fax:
Section 1
Name of MassHealth member:
Permission is given for the Casualty Recovery Unit and its representatives to share information listed in Section 2 about:
(Name of member whose information is to be shared)
Street
City/State/Zip
Date of Birth |
Telephone number |
MassHealth ID number
Please note: If you do not have a MassHealth ID number, please use your social security number.
Section 2
What information do you want shared? Please be aware that the information you are requesting us to share on your behalf may include financial information.
Check the box or boxes that apply.
□I am giving the Casualty Recovery Unit permission to share MassHealth Claims information pertaining to my accident which includes
MassHealth claims from: __________________ to ___________________
(month/year) |
(month/ year) |
□other (please be specific)
By giving the Casualty Recovery Unit this permission to share information, are you also giving the Casualty Recovery Unit permission to share drug and alcohol treatment information?
□Yes, Share drug and alcohol treatment information.
□No, Do not share drug and alcohol treatment information.
Section 3
Whom do you want us to share information with?
List the name of ONLY ONE person or organization in this section. You must fill out another PSI form if you want to name more than one person or organization.
Casualty Recovery Unit may share the information listed in Section 2 with
Name of Person or Organization
In care of (name of person in organization to whom mail should be sent)
Street
City/State/Zip
Telephone number
Fax Number
Casualty Recovery Unit relies on the contact information you provide. Please be certain this contact information is correct.
Section 4
Why do you want us to share your information?
Tell us why you want to share the information listed in Section 2. If you lea e this se tio la k, e ill assu e at y
e uest.
Section 5
End of Permission
This PSI will end in 18 months unless you specify an end date here. ________________________
Section 6
Your Signature
I understand the following:
When the person or organization named in Section 3 gets this information from the Casualty Recovery Unit, that person or organization may be able to share it with others without my permission. If they do so, federal and state privacy laws may not protect the information.
I need to send this PSI to the address on the front page.
I may cancel this permission at any time by sending a letter to:
Casualty Recovery Unit, P.O. Box 15205, Worcester, MA
Even if I cancel this permission, the Casualty Recovery Unit cannot take back any information that it shared when it had my permission to do so.
If I do not give the Casualty Recovery Unit Permission to share information, or if I cancel my permission to share information with the person or organization named in Section 3, my MassHealth benefits will not be affected in any way.
____________________________________
Name of Member (Print)
Signature of Member |
Date |
Section 7
Signature/Legal Guardian
Fill out the following section if this form is being filled out by someone who has the legal authority to act on behalf of the applicant or member (such as the parent of a
Printed name of person filling out this form
Signature of person filling out this form
Date
Address
Telephone number
Authority of person filling out this form to act on behalf of member.*
*If this form is being filled out by someone who has been appointed by a court as a legal guardian or conservator or who has power of attorney or