United Healthcare Release Of Information PDF Details

In an era where the confidentiality and management of healthcare information are paramount, the United Healthcare Release of Information form plays a crucial role. This document serves as a bridge, allowing individuals to authorize the sharing of their personal health details under various conditions, preserving the integrity and privacy of their medical records. At its core, the form embodies the individual's consent for United Healthcare to disclose or receive specific health information to or from designated entities. Critical aspects covered in the form include the voluntary nature of authorization, the protection of information under federal and state laws, and the specifics of the information eligible for release. It meticulously outlines the scenarios under which the data may be shared, ensuring individuals are informed about where their sensitive data could be sent and under what circumstances. Furthermore, it addresses the possibility of revoking consent, the conditions under which UnitedHealthcare will not condition services on the authorization, and state-specific provisions that cater to the unique legal environments across the United States. Additionally, the form delves into the procedural side, detailing how individuals can request to view the information shared and keep a copy for their records, thereby reinforcing the transparency and control individuals have over their personal health information.

QuestionAnswer
Form NameUnited Healthcare Release Of Information
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesauthorization unitedhealthcare understand, unitedhealthcare disclosed address, unitedhealthcare medical records request, united healthcare hipaa release form

Form Preview Example

Authorization for Release of Information

Member’s Name

 

Date of Birth

 

 

Member or Subscriber ID#

Chart #

 

 

 

 

 

 

 

 

 

 

Member’s Street Address

 

City

 

State

Zip Code

 

 

I understand that this authorization is voluntary. I understand that my health information may be protected by the Federal Rules for Privacy of Individually Identifiable Health Information (Title 45 of the Code of Federal Regulations, Parts 160 and 164), the Federal Rules for Confidentiality of Alcohol and Drug Abuse Patient Records (Title 42 of the Code of Federal Regulations, Chapter I, Part 2), and/or state laws. I understand that my health information may be subject to re-disclosure by the recipient and that if the organization or person authorized to receive the information is not a health plan or health care provider the information may no longer be protected by the Federal privacy regulations.

I understand that my health information may contain information created by other persons or entities including health care providers, and may also contain drug and alcohol, mental health, HIV/AIDS, psychotherapy, reproductive and sexually transmitted disease information. I further understand that by signing this document, I am authorizing the release or exchange of this information with the person or organization named below.

I understand that my health plan may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this form, except for certain eligibility or enrollment determinations prior to my enrollment in its health plan, and for health care that is solely for the purpose of creating protected health information for disclosure to a third party.

I understand that I may revoke this authorization at any time by notifying UnitedHealthcare in writing. However, the revocation will not have an effect on any actions UnitedHealthcare took before it received the revocation.

I authorize UnitedHealthcare to receive from or disclose my individually identifiable health information to the following person(s) or organization(s):

Name:

Address:

City

 

 

 

 

 

State

 

Zip

Phone Number: ( )

 

Extension

 

 

 

 

 

 

 

 

 

 

 

 

 

_______________________________________

 

 

 

 

UnitedHealthcare Authorization for Release of Information

Page 2

 

 

Description of individually identifiable health information to be received or disclosed (check appropriate type(s) of information):

All

Treatment Plan(s)

Claims

Progress Reports

Eligibility/Benefits

Attendance Only

Information used to make benefit determinations

 

All pertinent information UnitedHealthcare deems appropriate for the purpose checked below Other (describe):

The purpose of this authorization is (check all that apply):

To allow the appropriate management of treatment, services, and/or coverage under the member’s benefit plan.

Benefit Management

Administration of a Worker’s Compensation claim

Claims Administration/Payment

Administration of a Disability claim

Employer Mandated Treatment Referral

Subpoena or other legal process

Other (describe):

 

The dates of records to be disclosed:

From

_______ (MM/DD/YYYY) To

________ (MM/DD/YYYY)

 

 

 

 

 

THE MEMBER OR MEMBER’S REPRESENTATIVE MUST COMPLETE THE REST OF THIS FORM: I understand that this authorization will expire:

On

________ (MM/DD/YYYY)

 

 

OR

Once the following event occurs (does not apply to Illinois residents):

(Form must be completed before signing)

Signature of Member/Legal Guardian

 

Signature of Minor Member

 

Date

or Member’s Representative

 

 

 

 

 

 

 

Print Name of Member/Legal Guardian

 

Relationship to Member

 

Description of

or Member’s Representative

 

Representative’s Authority

 

 

 

 

(For Illinois residents only) Witness Signature

 

 

Date of Witness Signature

(For California and Georgia residents only) I understand that I may see and copy the information described on this form if I ask for it, and that I may receive a copy of this form after I sign it.

(For California and Georgia residents only) A copy of this form has been requested and received:

_____ Yes _____ No

PLEASE MAINTAIN A COPY OF THIS DOCUMENT FOR YOUR RECORDS

UnitedHealthcare Authorization for Release of Information

Page 3

 

 

Please return the completed form to:

UnitedHealthcare

Customer Service Privacy Unit

P O Box 740815

Atlanta, GA 30374-0815

PLEASE NOTE THE FOLLOWING STATE-SPECIFIC PROVISIONS:

Arizona: The request must be in writing and signed by the person requesting the medical records. The person requesting the medical records must demonstrate the authority to have access to the records.

California: The patient or the person signing this form has the right to receive a copy of the form. Authorization terminates upon the earlier termination of policy coverage, or 60 days after the termination of treatment.

Georgia: Advises that the individual, or the individual’s authorized representative, is entitled to receive a copy of the authorization form.

Illinois: A witness signature is required. The authorization must specify expiration date as a calendar date (i.e., month/day/year). If no calendar date is specified, the information may be released only on the day the consent form is received. Must include right to inspect and copy information to be disclosed. Must also include consequences of refusal to consent, if any. Records do not include information regarding HIV/AIDS status without an authorization that explicitly and specifically includes the release of such information.

Indiana: Expiration of the authorization may be a date, event or other condition. If no expiration is specified, the authorization is valid for 180 days after the date the request was made.

Iowa: The individual has the right to inspect the disclosed information at any time.

Minnesota: Authorization expires on the earlier of the specific date stated or one year from date signed.

Oregon: Unless revoked earlier, the authorization will expire 180 days from the date of signing or shall remain in effect for the period reasonable needed to complete the request.

Virginia: To be valid, the authorization must state the inclusive dates of the records to be disclosed.

Washington: Authorization expires on the earlier of the specific date stated or 90 days after signed, including authorization to release future health care information, except information to third party health care payors.

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Step 1: You can press the orange "Get Form Now" button at the top of the following page.

Step 2: The document editing page is currently available. It's possible to add text or change existing details.

You should provide the following information to prepare the unitedhealthcare medical records fax number PDF:

unitedhealthcare fax number for medical records fields to complete

Jot down the data in the I understand that I may revoke, I authorize UnitedHealthcare to, Name, Address, City, State, Zip, and Phone Number Extension area.

unitedhealthcare fax number for medical records I understand that I may revoke, I authorize UnitedHealthcare to, Name, Address, City, State, Zip, and Phone Number   Extension blanks to fill

Write the crucial particulars in Description of individually, All Claims EligibilityBenefits, Treatment Plans Progress Reports, The purpose of this authorization, To allow the appropriate, The dates of records to be, From MMDDYYYY To MMDDYYYY, THE MEMBER OR MEMBERS, I understand that this, and On MMDDYYYY segment.

Filling in unitedhealthcare fax number for medical records step 3

Through space Once the following event occurs, Form must be completed before, Signature of MemberLegal Guardian, Signature of Minor Member, Date, Print Name of MemberLegal Guardian, Relationship to Member, Description of Representatives, For Illinois residents only, Date of Witness Signature, For California and Georgia, and For California and Georgia, indicate the rights and obligations.

Finishing unitedhealthcare fax number for medical records stage 4

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