ASHLink - APR Form

Authorized Personal Representative-California Members

Please read this Authorized Personal Representative Form carefully and fill it out completely. If you prefer, you may print a PDF copy of the Authorized Personal Representative Form and either fax or mail it to ASH.

Check here if you are completing this form on behalf of the member

Member Information

First Name:

Health Plan ID Number:

Last Name:

Street Address:

Date of Birth:

Zip Code:

Telephone:

City:

Health Plan:

State:

Personal Representative Information

I authorize the following individual to receive my protected health information (PHI) and exercise any related privacy rights for the purpose noted below:

Personal Representative's address is the same as member's.

First Name:

Street Address:

Last Name:

Zip Code:

Telephone:

City:

Fax (optional):

State:

Purpose

The purpose of this authorization is limited to the following (please describe why this information is being disclosed):

Information to be Disclosed

This authorization is limited to the following PHI (select one or more on this section).

All records including, but not limited to, all chart entries, diagnoses, test results, and reports.

Only records relating to the following date(s) of service:

From

Through

Only records relating to the following diagnosis/symptoms:

Other (please explain):

I would like my authorized representative to have access to the following information. Indicate by checking (optional): Alcohol/Drug Treatment Mental Health Information HIV-Related Information

Acknowledgement & Signature

Submitting this form means that I understand and agree to the following:

I understand this Authorization is good for a period of one (1) year from the date I submit it. The Authorization will expire after that time period.

I understand that I may revoke this Authorization at any time by notifying American Specialty Health (ASH) in writing at: Attn: Privacy Officer, American Specialty Health, 10221 Wateridge Circle, San Diego, CA 92121. If the Authorization is revoked, it will not have any effect on disclosures that were made before my notification revoking this Authorization was received by ASH.

I understand that the Personal Representative designated above may exercise any and all privacy rights normally extended to the member identified above, including access to PHI about the member.

I understand that disclosures to the Personal Representative designated above will include application and enrollment information, eligibility information, claims records, claims status and member medical records information including information about chronic diseases, and/or genetic marker information about the identified member.

I understand this authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV-RELATED INFORMATION only if I select the appropriate line on this form in the section titled “INFORMATION TO BE DISCLOSED.” In the event the health information authorized to be disclosed includes any of these types of information, and I select the line in “INFORMATION TO BE DISCLOSED”, I specifically authorize release of such information to the person (s) indicated in the “PERSONAL REPRESENTATIVE INFORMATION” section.

If I am authorizing the release of HIV-RELATED INFORMATION, ALCOHOL or DRUG ABUSE TREATMENT, or MENTAL HEALTH TREATMENT information, the recipient may be prohibited from re-disclosing such information without my authorization unless permitted to do so under federal or state law.

I understand that this Authorization is voluntary. ASH is able to provide treatment or process payment, enrollment, or eligibility for benefits without this authorization. ASH will not deny treatment, payment, enrollment, or eligibility for benefits if I do not submit this authorization, except in the case of: (a) research related treatment; (b) pre-enrollment underwriting or risk determination; or (c) provision of health care solely for the purpose of creating PHI for disclosure to a third party.

I understand the disclosed PHI may be subject to re-disclosure by the recipient and may no longer be protected by the federal privacy law.

I authorize American Specialty Health Incorporated and any of its parents, subsidiaries, or other affiliates that manage my benefits, to disclose PHI about the member listed above.

I hereby certify that I have read, understand and agree to the terms of this document and designate the individual listed above as the identified member's Personal Representative.

Name:

Date:

Relationship to Member:

Self
Personal Representative
Other (Complete the information below)

If this request is being made by an individual other than the member, please complete the information below, describe your authority to make this request on the member's behalf and include copies of supporting documentation:

First Name:

Street Address:

Last Name:

Zip Code:

Telephone:

City:

State:

Description of Representative's Authority to Act/Relationship to Member (choose one):
(Must print form and fax or mail – online submissions for the following are not permitted.)

Member is a minor and I am the member's parent or legal guardian.
Member is deceased and I am the member's surviving spouse or next of kin, the executor/administrator of the member's estate, hold durable power of attorney, or I am otherwise legally authorized to act on behalf of a deceased member or the member's estate (please attach necessary documentation).
I am the member's agent, as designated in the member's Durable Power of Attorney for Health Care (please attach necessary documentation).
Other (please describe and attach necessary documentation):

If you need assistance, please contact Member Services at 800.678.9133.

AUTHORIZED PERSONAL REPRESENTATIVE-CALIFORNIA MEMBERS

First Name:

Health Plan ID Number:

Last Name:

Street Address:

Date of Birth:

Zip Code:

Telephone:

City:

Health Plan:

State:

First Name:

Street Address:

Last Name:

Zip Code:

Telephone:

City:

Fax(Optional):

State:

The purpose of this authorization is limited to the following:

This authorization is limited to the following PHI:

I would like my authorized representative to have access to the following information:

Submitting this form means that I understand and agree to the following:

I understand this Authorization is good for a period of one (1) year from the date I submit it. The Authorization will expire after that time period.

I understand that I may revoke this Authorization at any time by notifying American Specialty Health (ASH) in writing at: Attn: Privacy Officer, American Specialty Health, 10221 Wateridge Circle, San Diego, CA 92121. If the Authorization is revoked, it will not have any effect on disclosures that were made before my notification revoking this Authorization was received by ASH.

I understand that the Personal Representative designated above may exercise any and all privacy rights normally extended to the member identified above, including access to PHI about the member.

I understand that disclosures to the Personal Representative designated above will include application and enrollment information, eligibility information, claims records, claims status and member medical records information including information about chronic diseases, and/or genetic marker information about the identified member.

I understand this authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV-RELATED INFORMATION only if I select the appropriate line on this form in the section titled “INFORMATION TO BE DISCLOSED.” In the event the health information authorized to be disclosed includes any of these types of information, and I select the line in “INFORMATION TO BE DISCLOSED”, I specifically authorize release of such information to the person (s) indicated in the “PERSONAL REPRESENTATIVE INFORMATION” section.

If I am authorizing the release of HIV-RELATED INFORMATION, ALCOHOL or DRUG ABUSE TREATMENT, or MENTAL HEALTH TREATMENT information, the recipient may be prohibited from re-disclosing such information without my authorization unless permitted to do so under federal or state law.

I understand that this Authorization is voluntary. ASH is able to provide treatment or process payment, enrollment, or eligibility for benefits without this authorization. ASH will not deny treatment, payment, enrollment, or eligibility for benefits if I do not submit this authorization, except in the case of: (a) research related treatment; (b) pre-enrollment underwriting or risk determination; or (c) provision of health care solely for the purpose of creating PHI for disclosure to a third party.

I understand the disclosed PHI may be subject to re-disclosure by the recipient and may no longer be protected by the federal privacy law.

I authorize American Specialty Health Incorporated and any of its parents, subsidiaries, or other affiliates that manage my benefits, to disclose PHI about the member listed above.

I hereby certify that I have read, understand and agree to the terms of this document and designate the individual listed above as the identified member's Personal Representative:

Name: Date:

Relationship to Member:

Authorized Personal Representative-California Members

Member Information

Personal Representative Information

Purpose

Information to be Disclosed

Acknowledgement & Signature

Thank You!

AUTHORIZED PERSONAL REPRESENTATIVE-CALIFORNIA MEMBERS

MEMBER INFORMATION

PERSONAL REPRESENTATIVE INFORMATION

PURPOSE

INFORMATION TO BE DISCLOSED

ACKNOWLEDGEMENT & SIGNATURE

Authorized Personal Representative-California Members

Member Information

Personal Representative Information

Purpose

Information to be Disclosed

Acknowledgement & Signature

Thank You!

AUTHORIZED PERSONAL REPRESENTATIVE-CALIFORNIA MEMBERS

MEMBER INFORMATION

PERSONAL REPRESENTATIVE INFORMATION

PURPOSE

INFORMATION TO BE DISCLOSED

ACKNOWLEDGEMENT & SIGNATURE

Notice