Authorization to Release
Protected Health Information (PHI) Form
Do you want to give someone access to your health information?
Complete and sign this form and return it by mail, fax, or email. If you’d like help, call the Member Services
phone number on your Healthfirst Member ID card.
Please sign this form or it cannot be processed.
Section 1 Member Information (person whose information will be released)
First Name Middle Initial Last Name
Member ID Date of Birth (MM/DD/YYYY) Phone Number
Mailing Address (Include Apt., Bldg.)
City State Zip Code
Email
Section 2 Who are you sharing your information with?
○ Spouse ○ Domestic Partner ○ Adult Child ○ Parent
○ Other:
Full Name of Person or Name of Organization
Mailing Address (Include Apt., Bldg.)
City State Zip Code
Phone Number Email (Optional)
Healthfirst | Authorization to Release Protected Health Information (PHI) Form Page 1 of 3
Section 3 Reason for Authorization Request
I authorize Healthfirst to:
" Discuss my health information with the person or organization listed in Section 2
Please specify the type of personal health information you wish to share.
You must check all types of information that you want to share.
" Claims " Billing/Enrollment " Appeals and Grievances
" Health Records " Pharmacy Records
Sensitive Information (to select, please check the box and write your initials):
" All Sensitive Information
" Mental Health " HIV/AIDS " Sexually Transmitted Infections (STI)
" Reproductive/Family Planning Health
" Substance Use Disorder (SUD)
○ All of my SUD Information
○ Only the following (be specific; for example: discharge summary only, labs only,
paid claims only, authorizations only):
Healthfirst | Authorization to Release Protected Health Information (PHI) Form Page 2 of 3
Section 4 Attestation and Signature
By signing below, I understand and agree: My signature is required if any of the below apply:
Healthfirst will not share my PHI with the person or • I am 18 years of age or older
organization named in Section 2 unless I sign, date, • I am a minor under the age of 18 and I am either
and return this form. married or emancipated
• This authorization is voluntary and is valid for two • The information being disclosed pertains to drug or
years from the date it is received. alcohol treatment
• Healthfirst cannot base decisions regarding my • The information being disclosed pertains to one of
treatment, enrollment, or eligibility for benefits on the following conditions, and my state allows me
whether I submit this form. to be treated even if my parents or legal guardian
• I can cancel or change my authorization at any do not agree with my decision:
time by contacting Healthfirst Member Services Mental health/substance use disorder
using the contact information at the bottom of
this form. If I cancel my authorization, it will not Sexually transmitted disease
affect any actions Healthfirst takes before my (including HIV/AIDS)
cancellation request is received. Reproductive health (including contraception,
• My PHI that I share may be sensitive. If I share my prenatal care, and abortion)
PHI with an organization that is not a health plan or General medical and dental health
healthcare provider, my PHI may not be protected
by privacy laws (with the exception of HIV/AIDS or
Substance Use Disorder-related information).
Member or Legal Representative
Signature SIGN HERE
Print Name Date (MM/DD/YYYY)
" Member " Legal Representative
Signature must match name in Section 1. Legal representative must attach copies of
authorization to act on member’s behalf. (e.g., Power
of Attorney, Guardianship, Executor of Estate, etc.)
Return this signed, completed form and any relevant documentation to:
Healthfirst Member Services
Mail: P.O. Box 5165, New York, NY 10275-0308
Fax: 1-212-801-3250
Email:
[email protected] Don’t forget to sign and date this form in Section 4.
1731-23 Y0147_MSD23_261 1731-23_C XP23_216
Healthfirst | Authorization to Release Protected Health Information (PHI) Form Page 3 of 3
