Authorization to Disclose Health Information

Notice to Member:

Completing this form will allow Community First Health Plans to (i) use your health information for a particular purpose, and/or (ii) share your health information with the individual or entity that you identify on this form.
You do not have to give permission to use or share your health information. Your services and benefits with Community First Health Plans will not change if you do not submit this form.
If you want to cancel this authorization form, send us a written request to revoke it at the address on the bottom of this page. A revocation form can be provided to you by calling Member Services at the phone number on the back of your member ID card.
Community First Health Plans cannot promise that the person or group you allow us to share your health information with will not share it with someone else.
Keep a copy of all completed forms that you send to us. We can send you copies if you need them.
If you need help or if you have questions about this form, please call Community First Health Plans.

PLEASE READ THE INSTRUCTIONS CAREFULLY AND COMPLETE THE FORM BELOW. INCOMPLETE FORMS CANNOT BE ACCEPTED.

1. MEMBER INFORMATION:

Member Name*(Required)

First Last

Member Date of Birth*(Required)

Member ID Number *(Required)

Member Email Address*(Required)

2. I GIVE COMMUNITY FIRST HEALTH PLANS PERMISSION TO USE MY HEALTH INFORMATION FOR THE PURPOSE IDENTIFIED OR TO SHARE MY HEALTH INFORMATION WITH THE PERSON OR GROUP NAMED BELOW. THE PURPOSE OF THE AUTHORIZATION IS EITHER (check one option below):(Required)

to allow Community First Health Plans to help me with my benefits and services

to permit Community First Health Plans to use or share my health information

3. PERSON(S) OR GROUP(S) TO RECEIVE INFORMATION:
Note: Add more persons or groups in Section 7: ADDITIONAL INDIVIDUAL PERSON(S) OR GROUP(S) TO RECEIVE INFORMATION.

Name (Person or Group)

Address

Street Address Address Line 2 City State ZIP Code

Phone

NOTE: If you are consenting to disclose any substance use disorder records to a recipient that is neither a third party payor nor a health care provider, facility, or program where you receive services from a treating provider, such as a health insurance exchange or a research institution (hereafter, “recipient entity”), you must specify the name of an individual with whom or the entity at which you receive services from a treating provider at that recipient entity, or simply state that your substance use disorder records may be disclosed to your current and future treating providers at that recipient entity.

4. I AUTHORIZE COMMUNITY FIRST HEALTH PLANS TO USE OR SHARE THE FOLLOWING HEALTH INFORMATION:(Required)

Please Note: Select the first statement to release ALL health information or select the below statement to release only SOME health information. Both CANNOT be selected.

All of my health information INCLUDING: Genetic information, services or test results; HIV/AIDS data and records; mental health data and records (but not psychotherapy notes); prescription drug/medication data and records; and drug and alcohol data and records (please specify any substance use disorder information that may be disclosed);

All of my health information EXCEPT (check all boxes below that apply):

All of my health information EXCEPT (check all boxes below that apply)(Required)

Genetic information, services or tests

AIDS or HIV data and records

Drug and alcohol data and records

Mental health data and records (but not psychotherapy notes)

Prescription drug/medication data and records

Other

A Community First Health Plans representative will contact you by email for additional details. Please provide your email address: *(Required)

5. AUTHORIZATION END DATE:

Using the calendar that populates, please enter the date you would like this authorization to end. If this field is blank, the authorization expires one year from the date of the signature below. DATE CANNOT BE THE CURRENT DATE OR THE AUTHORIZATION WILL BE DENIED.

6. Member or Legal Authorized Representative Signature:(Required)

By typing in my name, I am attesting that I am the individual in question and am providing my consent for this authorization.

Date(Required)

IF LEGAL REPRESENTATIVE - Relationship to Member

I confirm I am the member or the members Legally Authorized Representative (if member is younger than 18 years of age).(Required)

I confirm I am the member or the members Legally Authorized Representative (if member is younger than 18 years of age).

If you are the member’s legal or personal representative, you must send us copies of relevant forms, such as power of attorney or order of guardianship. MAIL ANY SUPPORTING DOCUMENTATION TO COMMUNITY FIRST MEMBER SERVICES, 12238 Silicon Drive, Suite 100. San Antonio, Texas 78249

7. ADDITIONAL INDIVIDUAL PERSON(S) OR GROUP(S) TO RECEIVE INFORMATION:

Add Second Person

Add Third Person

Add Fourth Person

Add Fifth Person

Add Sixth Person

If you agree to receive PHI information from Community Firsth Health Plans via email, please fill out the following field: Name of Individual Completing this Form:(Required)

(Member [you], Parent, Caregiver or Legally Authorized Representative of Member)