The Authorization for Release of Information form is required according to the guidelines set forth in the Health Insurance Portability and Accountability Act (HIPAA), specifically 45 CFR § 164.508 of the HIPAA Regulations.
The following is a description of how the form should be completed.
Section 1 - Plan and member information
Section 2 - Who is to release the information, e.g. Meritain Health
Section 3 - What information you want released, e.g. all information related to my plan
Section 4 - Whom do you want to receive the information, e.g. your spouse, child, friend, etc.
Section 5 - Why you want the information to be released
The authorization should be signed by the member whose information is to be released.
All sections of the form must be completed for the form to be considered. Please forward this completed form to the Privacy Officer of the employer or to:
Attn: HIPAA Compliance Officer
PO Box 1671
Amherst, NY 14226-7671
Click here to view a sample completed form.
Click here to print a blank form to complete and send to Meritain Health.