State Employee & Retiree Release of Records Form
This form authorizes the release and use of confidential health information for state employees and retirees. It allows the disclosure of details such as enrollment, eligibility, claims records, and more. The form must be signed by the individual and a witness, and may be revoked under certain circumstances.
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How do I fill this out?
To fill out this form, provide your personal information, select the entities authorized to disclose or obtain your health information, and indicate the specific information and reasons for the disclosure. Make sure to read your rights to revoke the authorization.
How to fill out the State Employee & Retiree Release of Records Form?
1
Provide your personal identification information in Section A.
2
Select the entities authorized to disclose or obtain your information in Sections B.1a and B.1b.
3
Specify the type of information and reasons for disclosure in Sections B.2 and B.3.
4
Read and understand your rights to revoke the authorization in Section C.
5
Sign the form with a witness and provide any additional legal representative information if applicable.
Who needs the State Employee & Retiree Release of Records Form?
1
State employees needing to share their health information for claim reviews and appeals.
2
Retirees requiring assistance with plan coverages and benefits.
3
Employees needing to authorize the disclosure of their dependents' health information for various purposes.
4
Legal or personal representatives acting on behalf of an individual needing to obtain or release health information.
5
Employees needing to authenticate the request for their protected health information by providing necessary documentation.
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Use the editing tools to fill in your personal information and check relevant boxes.
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What are the instructions for submitting this form?
Complete the form accurately, ensuring all necessary information is provided. Submit the form to: Employee Benefits Division, HIPAA Privacy Officer, Room 510, 301 W. Preston Street, Baltimore, MD 21201. You can also fax the form to 410-333-7104. Email submission is not accepted. It is advisable to keep a copy of the completed form for your records.
What are the important dates for this form in 2024 and 2025?
Ensure to submit this form before its expiration date, one year from the date it is signed. Keep a copy of the completed form for your records, and contact the HIPAA Privacy Officer if you need to revoke the authorization.
What is the purpose of this form?
The purpose of this form is to authorize the use and/or disclosure of confidential protected health information for state employees and retirees. This Legal/Personal Representative for a smooth and straightforward completion. form allows for the inclusion of enrollment details, premium information, and other relevant data for the intended individuals. By completing and signing this form, individuals can have their necessary information disclosed in a controlled manner, ensuring that claims, benefits, and other plan-related assistance are managed efficiently.
Tell me about this form and its components and fields line-by-line.
- 1. A. Identification: Contains personal details such as Name, Address, Date of Birth, Daytime Phone Number, and Social Security Number.
- 2. B. Directions for Release: Sections B.1a and B.1b list authorized entities for disclosure and obtaining information. Section B.2 specifies types of information authorized for release. Section B.3 indicates reasons for disclosure.
- 3. C. Right to Revoke: Explains the right to revoke the authorization and provides instructions for contacting the HIPAA Privacy Officer.
- 4. D. Authorization and Signature: Requires the individual's signature along with a witness's signature and date to validate the authorization.
- 5. E. Legal Representative: For legal or personal representatives, this section requires completing details such as the representative’s name, signature, and documentation of authorization such as Power of Attorney.
What happens if I fail to submit this form?
Failing to submit this form may result in delays or inability to process claims, reviews, and appeals related to health and welfare benefits.
- Claims Processing Delays: Without this form, claims related to your health benefits may not be processed in a timely manner.
- Inability to Review or Appeal Claims: If not submitted, you may lose the opportunity to review or appeal any decisions made about your claims.
- Limited Access to Health Information: Failure to provide this form may restrict access to necessary health information for plan coverages and benefits.
How do I know when to use this form?
- 1. Claim Reviews: Authorize health information disclosure for reviewing health benefit claims.
- 2. Assistance with Plan Coverages: Allow the release of information needed for assisting with your plan coverages and benefits.
- 3. Dependent's Benefits: Use this form to authorize information disclosure for your dependent's health benefits.
- 4. Personal Representative Actions: If a legal or personal representative needs to access your health information, this form is necessary.
- 5. Plan Decisions and Appeals: Needed for plan reviews, coverage decisions, and appeal processes.
Frequently Asked Question
How do I fill out the identification section?
Provide your name, address, date of birth, daytime phone number, and Social Security Number. If you’re filling it out for someone else, include their details as well.
Who can authorize the release of information?
The individual whose information is being disclosed or their legal/personal representative can authorize the release.
What types of information can be disclosed?
Information such as specific claims, entire medical records, enrollment, eligibility, premium payment records, and any other specified information can be disclosed.
How do I revoke the authorization?
You can revoke the authorization by contacting the Employee Benefits Division HIPAA Privacy Officer in writing or via fax.
Do I need a witness signature?
Yes, both your signature and a witness signature are required for the form to be valid.
What should a legal representative provide?
A legal representative needs to provide a Power of Attorney or relevant documents designating them as the representative, along with their contact information.
Where do I submit the completed form?
Submit the form to the Employee Benefits Division HIPAA Privacy Officer at the provided address or fax number.
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