Fillable AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION (John Hopkins Medicine Medicare Plan)

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AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION (John Hopkins Medicine Medicare Plan)

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AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION
By completing this document, you authorize the disclosure and/or use of your individually identifiable health
information, as set forth below, consistent with Federal law concerning the privacy of such information.
Failure to provide all information may invalidate this Authorization.
Member Demographics
Name: ___________________________________________________________________________
Address: __________________________________________________________________________
ID Number: ___________________________________________ Date of Birth: ________________
I, __________________________________________ (your name), authorize Johns Hopkins Advantage
MD (HMO) and Johns Hopkins Advantage MD (PPO) to disclose my health information.
Person/Organization I authorize to receive my health information:
Name/Organization: __________________________________________________________________
Address: __________________________________________________________________________
City, State and Zip: __________________________________________________________________
Phone Number: _____________________________________________________________________
What relationship is this person to you? ___________________________________________________
This Authorization applies to All Health Information including health (e.g., diagnosis, providers, treatments,
drugs), eligibility, enrollment and financial information (e.g., medical claims, premium bills, copayments),
substance abuse, mental health, HIV, etc.
As required by the Health Information Portability and Accountability Act if 1996, you have a right to nominate
one or more persons to act on your behalf with respect to your protected health information (PHI). Your
Personal Representative is given all of the privileges that you have with respect to your PHI. Your Personal
Representative may receive your PHI and also has the authority to modify your Johns Hopkins Advantage MD
health plan account (e.g., update your address change your Primary Care Physician). A personal representative
may be a spouse, relative, domestic partner or friend.
You are not required to have a Personal Representative, but if you want to designate someone who can
receive your PHI and modify your Johns Hopkins Advantage MD health plan account, please complete the
information below and attach appropriate documentation authorizing the representation (e.g., Power of
Attorney [POA]).
The person named below (same as individual named in Section 1) is to also be given all of the
privileges that would be given to me regarding my protected health information.
Personal Representative Name: _________________________________________________________
(Individual named in Section 1)
Y0124_MAAuthForm0720_C
1. USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
2. DESIGNATION OF PERSONAL REPRESENTATIVE
Y0124_MAAuthForm0720_C
This document will be in effect until my coverage with Johns Hopkins Advantage MD health plan ends or until I
send a written request to revoke this authorization.
I may refuse to sign this authorization. I understand that Johns Hopkins Advantage MD health plan will not
condition treatment, payment, enrollment or eligibility for benefits on my providing or refusing to provide this
authorization, except under limited circumstances described in the Notice of Privacy Practices.
I may revoke this authorization at any time by signing the revocation section and sending this for to Johns
Hopkins Advantage MD health plan. My revocation will be effective upon receipt but will not be effective to
the extent that other have acted in reliance upon this authorization.
I have a right to receive a copy of this authorization.
I understand information disclosed pursuant to this authorization could be re-disclosed by the recipient and
might not be protected by federal confidentiality law (HIPAA).
I may inspect or obtain a copy of the health information I am authorizing for use or disclosure.
I understand that Johns Hopkins Advantage MD health plan may not use or disclose my PHI other than for
the purposes described on this form unless another authorization is obtained from me or unless such use or
disclosure is specifically required or permitted by law.
I hereby release Johns Hopkins Advantage MD health plan from any and all liability that may arise from the
release of this information to the party named on this form.
The medical information released may contain information related to HIV status, AIDS, sexually transmitted
diseases, mental health, drug and alcohol abuse, etc.
Please print your name: _______________________________________________________________
Johns Hopkins Advantage MD health plan ID number: ________________________________________
Signature: ________________________________ Date: _________________________________
If signed by someone other than the member (such as a guardian or conservator), please complete the
following:
Printed name: ___________________________________ Relationship: ______________________
All pages of this form must be faxed or mailed to:
Johns Hopkins Advantage MD
P.O. Box 3538
Scranton, PA 18505
Fax: 1-855-206-9203
You may revoke this authorization at any time by signing and dating this section of the form and returning it to
Johns Hopkins Advantage health plan. You should only sign this section if you want to cancel this
authorization.
I hereby revoke this authorization and/or designation or personal representative immediately.
Signature: ________________________________ Date: _________________________________
3. EXPIRATION
4. NOTICE OF RIGHTS AND OTHER INFORMATION
5. SIGNATURE
6. SUBMISSION
7. REVOCATION
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AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION (John Hopkins Medicine Medicare Plan)

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Completed 25 May 2021

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