Member Authorization Instructions
Member Authorization Allowing the Disclosure of Protected Health Information to another Person/Entity
In order for this authorization to be valid, the following areas must be completed:
- Patient Name
- ID #
- Date of Birth
- Group Name
- Group #
- The name and address of the recipient or class of recipients to whom the information may be disclosed or used. This may be an individual’s name. It may also be a ‘class’ of recipients such as the ‘Human Resources department at ABC Company’.
- The purpose(s) for the disclosure. The individual should indicate specifically the reasons that they are asking for information to be shared.
Examples of valid reasons are:
- To discuss the payment of claim #123456789
- To discuss claim payment concerns for all claims that were sent to ODS relating to my hospitalization of 12/1/2005 to 6/15/06
- To discuss all information related to my insurance coverage, treatment and payment
- HIV/AIDS test or result information and related records. If the member desires that we share information, the member must writer their initials on this line. No initial or any mark other than the member's initial will indicate that no information about this condition is to be shared.
- Mental health information. If the member desires that we share this information, the member must write their initials on this line. No initial or any mark other than the member's initial will indicate that no information about this condition is to be shared.
- Genetic testing information. If the member desires that we share this information, the member must write their initials on this line. No initial or any mark other than the member's initial will indicate that no information about this condition is to be shared.
- Drug/alcohol diagnosis, treatment or referral information. If the member desires that we share information specifically related to this sensitive condition, the member must initial this line. No initial indicates that no information about this condition is to be shared.
- Either the date or event box must be checked and filled out.
- If the date box is checked, there must also be a valid future expiration date. The expiration date cannot extend beyond 24 months (2 years) from the date of the requestor's signature (in the signature box)
- If the event box is checked, then the event must also be listed.
Examples would include: - Conclusion of Appeal II
- Independent Review of surgical request
Under Oregon State Law, an authorization is valid for a maximum of 24 months. If the event stated is still active 24 months from the date of the authorization, a new authorization will need to be sent to ODS. Extensions to existing authorizations are not accepted. An authorization may only be continued past the originally designated period by the completion and submission of a new authorization.
**Please do not put in “until my death,” “until my coverage terminates” or “until I revoke it” as an event or date. We will return an authorization with this event as being invalid.
- The authorization must be signed and dated by the individual making the request in order to be valid. If a personal representative of the member is signing on behalf of the member, the applicable information must be attached.
- The name or other specific identification of the person(s) or class of persons authorized to make the requested use or disclosure
- Using checkmarks (√) or x’s (x) rather than initials if indicating that information related to HIV, Mental Health, genetic testing or Drug/Alcohol related information can be shared.
- The expiration date or an expiration event that relates to the individual or the purpose of the use and disclosure.
- The signature of the individual and date
- If the authorization is signed by a personal representative of the individual, a description of such representative’s authority to act for the individual and the required documentation.