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

1. MEMBER INFORMATION:

2. I GIVE HOME STATE HEALTH 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: (Check one option below) 

to allow Home State Health to help me with my benefits and services, OR

3. PERSON(S) OR GROUP(S) TO RECEIVE INFORMATION:

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

4. I AUTHORIZE HOME STATE HEALTH TO USE OR SHARE THE FOLLOWING HEALTH INFORMATION

(Note: Select the first statement to release ALL health information or select second statement to release only SOME health information. Both CANNOT be selected.)
check only the boxes below that apply

5. THIS AUTHORIZATION ENDS ON THIS DATE/EVENT (mm/dd/yyyy) (Date this authorization ends unless cancelled). 

If this field is blank, the authorization expires one year from the date of the signature below).

-------------------------------------------------------------------------------------------------------

6. SIGNATURE

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

Legally Authorized Representative

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

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.

-------------------------------------------------------------------------------------------------------

-------------------------------------------------------------------------------------------------------

-------------------------------------------------------------------------------------------------------

-------------------------------------------------------------------------------------------------------

HSH24041-10/26/23