Authorization to Disclose Health Information
Notice to Member:
- Completing this form will allow Home State Health 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 Home State Health 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.
- Home State Health 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, contact Member Services at the phone number on the back of your member ID card.
- Fill in all the information on this form.
- For more information: Phone: 1-855-694-4663 (Hearing Impaired TTY 711)
PLEASE READ THE INSTRUCTIONS CAREFULLY AND COMPLETE THE FORM BELOW
INCOMPLETE FORMS CANNOT BE ACCEPTED