MARYLAND HEALTH BENEFIT EXCHANGE
RELEASE OF INFORMATION AUTHORIZATION FORM
COMPLETE ALL SECTIONS, DATE, AND SIGN
I. I,
Print Name of Individual
, hereby voluntarily authorize the disclosure of my Personally Identifiable
Information related to my application for health insurance, Advanced Payment
Tax Credits, Cost Reduction Sharing and/or other benefits provided to the
Maryland Health Benefit Exchange.
II. The information is to be disclosed by:
And is to be provided to:
NAME OF FACILITY
NAME OF PERSON/ORGANIZATION/FACILITY
ADDRESS ADDRESS
CITY/STATE CITY/STATE
III. The purpose or need for this disclosure is:
Personal Use Attorney Disability Other (Specify)
Insurance
School
IV. The information to be disclosed from my enrollment application(s): (check appropriate box(es))
Only information related to (specify)
Only the period of events from to
Other (specify)
Entire Record
Written correspondence generated by MHBE related to my application.
If you would like any following sensitive information not to be disclosed, please list:
_______________________________________________________________________________________________________________________
V. I understand that I may revoke this authorization in writing submitted at any time to the MHBE Custodian of Records, except to the extent that
action has been taken in reliance on this authorization. If this authorization was obtained as a condition of obtaining insurance coverage or a policy of
insurance, other law may provide the insurer with the right to contest a claim under the policy. If this authorization has not been revoked, it will terminate
one year from the date of my signature unless a different expiration date or expiration event is stated.
(Specify new date)
I understand that MHBE will not condition eligibility for cost saving reductions, APTC or other benefits on my providing this authorization. This authorization
extends only to the records generated by MHBE and does not include records created by third parties. It is my responsibility to request records directly
from the generating party.
I understand that information disclosed by this authorization may be subject to re-disclosure by the recipient and may no longer be protected under
Maryland law and the Privacy Act of 1974 [5 USC 552a].
SIGNATURE OF INDIVIDUAL OR AUTHORIZED REPRESENTATIVE (State relationship to individual)
DATE
SIGNATURE OF WITNESS (If signature of individual is a thumbprint or mark)
DATE
This information is to be released for the purpose stated above and may not be used or re-disclosed by the recipient for any other purpose. Any person who knowingly and willfully
requests or obtains any record concerning an individual from a State agency under false pretenses shall be guilty of a misdemeanor.
The below information must be
completed in its entirety in order for MHBE to release the requested information.
ADDRESS DATE OF BIRTH (mm/dd/yyyy)
STREET CITY, STATE, AND ZIP CODE
NAME (Last, First, MI)
Last 5 digits of Record Holder’s OR MHBE Personal Identification Number
Social Security Number (PIN)
MHBE – 02.01.01.01 Release of Information Authorization Form 5-12-2020
Office of the Attorney General
Maryland Health Connection
Health Education and Advocacy Unit
200 St. Paul Place, 16th Floor
