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The United Healthcare Release of Information form is a vital document for members who wish to authorize the disclosure or receipt of their health information to or from a designated person or organization. This comprehensive form covers various aspects, including the member's personal and contact details, a declaration of understanding regarding the voluntarily nature of authorization, and an acknowledgment of the laws protecting health information. It emphasizes that the information released may include sensitive data such as drug and alcohol use, mental health, HIV/AIDS, and reproductive health details. The form outlines the purposes for which the information may be used, ranging from treatment and service management to claims administration and legal processes. Members are informed of their right to revoke the authorization at any time, although revocations will not affect previously taken actions based on the authorization. Additionally, specific information types and purposes for the disclosure are to be detailed by the member, alongside the specification of the information’s receiver. State-specific provisions ensure compliance with local regulations, highlighting the form’s adaptability to different legal requirements. This form not only facilitates the sharing of critical health information but also reinforces the importance of privacy and the member's control over their personal health data. Members are encouraged to keep a copy for their records and are provided with instructions on returning the completed document to United HealthCare's Customer Service Privacy Unit.

Document Example

Authorization for Release of Information

Member’s Name

 

Date of Birth

 

 

Member or Subscriber ID#

Chart #

 

 

 

 

 

 

 

 

 

 

Member’s Street Address

 

City

 

State

Zip Code

 

 

I understand that this authorization is voluntary. I understand that my health information may be protected by the Federal Rules for Privacy of Individually Identifiable Health Information (Title 45 of the Code of Federal Regulations, Parts 160 and 164), the Federal Rules for Confidentiality of Alcohol and Drug Abuse Patient Records (Title 42 of the Code of Federal Regulations, Chapter I, Part 2), and/or state laws. I understand that my health information may be subject to re-disclosure by the recipient and that if the organization or person authorized to receive the information is not a health plan or health care provider the information may no longer be protected by the Federal privacy regulations.

I understand that my health information may contain information created by other persons or entities including health care providers, and may also contain drug and alcohol, mental health, HIV/AIDS, psychotherapy, reproductive and sexually transmitted disease information. I further understand that by signing this document, I am authorizing the release or exchange of this information with the person or organization named below.

I understand that my health plan may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this form, except for certain eligibility or enrollment determinations prior to my enrollment in its health plan, and for health care that is solely for the purpose of creating protected health information for disclosure to a third party.

I understand that I may revoke this authorization at any time by notifying UnitedHealthcare in writing. However, the revocation will not have an effect on any actions UnitedHealthcare took before it received the revocation.

I authorize UnitedHealthcare to receive from or disclose my individually identifiable health information to the following person(s) or organization(s):

Name:

Address:

City

 

 

 

 

 

State

 

Zip

Phone Number: ( )

 

Extension

 

 

 

 

 

 

 

 

 

 

 

 

 

_______________________________________

 

 

 

 

UnitedHealthcare Authorization for Release of Information

Page 2

 

 

Description of individually identifiable health information to be received or disclosed (check appropriate type(s) of information):

All

Treatment Plan(s)

Claims

Progress Reports

Eligibility/Benefits

Attendance Only

Information used to make benefit determinations

 

All pertinent information UnitedHealthcare deems appropriate for the purpose checked below Other (describe):

The purpose of this authorization is (check all that apply):

To allow the appropriate management of treatment, services, and/or coverage under the member’s benefit plan.

Benefit Management

Administration of a Worker’s Compensation claim

Claims Administration/Payment

Administration of a Disability claim

Employer Mandated Treatment Referral

Subpoena or other legal process

Other (describe):

 

The dates of records to be disclosed:

From

_______ (MM/DD/YYYY) To

________ (MM/DD/YYYY)

 

 

 

 

 

THE MEMBER OR MEMBER’S REPRESENTATIVE MUST COMPLETE THE REST OF THIS FORM: I understand that this authorization will expire:

On

________ (MM/DD/YYYY)

 

 

OR

Once the following event occurs (does not apply to Illinois residents):

(Form must be completed before signing)

Signature of Member/Legal Guardian

 

Signature of Minor Member

 

Date

or Member’s Representative

 

 

 

 

 

 

 

Print Name of Member/Legal Guardian

 

Relationship to Member

 

Description of

or Member’s Representative

 

Representative’s Authority

 

 

 

 

(For Illinois residents only) Witness Signature

 

 

Date of Witness Signature

(For California and Georgia residents only) I understand that I may see and copy the information described on this form if I ask for it, and that I may receive a copy of this form after I sign it.

(For California and Georgia residents only) A copy of this form has been requested and received:

_____ Yes _____ No

PLEASE MAINTAIN A COPY OF THIS DOCUMENT FOR YOUR RECORDS

UnitedHealthcare Authorization for Release of Information

Page 3

 

 

Please return the completed form to:

UnitedHealthcare

Customer Service Privacy Unit

P O Box 740815

Atlanta, GA 30374-0815

PLEASE NOTE THE FOLLOWING STATE-SPECIFIC PROVISIONS:

Arizona: The request must be in writing and signed by the person requesting the medical records. The person requesting the medical records must demonstrate the authority to have access to the records.

California: The patient or the person signing this form has the right to receive a copy of the form. Authorization terminates upon the earlier termination of policy coverage, or 60 days after the termination of treatment.

Georgia: Advises that the individual, or the individual’s authorized representative, is entitled to receive a copy of the authorization form.

Illinois: A witness signature is required. The authorization must specify expiration date as a calendar date (i.e., month/day/year). If no calendar date is specified, the information may be released only on the day the consent form is received. Must include right to inspect and copy information to be disclosed. Must also include consequences of refusal to consent, if any. Records do not include information regarding HIV/AIDS status without an authorization that explicitly and specifically includes the release of such information.

Indiana: Expiration of the authorization may be a date, event or other condition. If no expiration is specified, the authorization is valid for 180 days after the date the request was made.

Iowa: The individual has the right to inspect the disclosed information at any time.

Minnesota: Authorization expires on the earlier of the specific date stated or one year from date signed.

Oregon: Unless revoked earlier, the authorization will expire 180 days from the date of signing or shall remain in effect for the period reasonable needed to complete the request.

Virginia: To be valid, the authorization must state the inclusive dates of the records to be disclosed.

Washington: Authorization expires on the earlier of the specific date stated or 90 days after signed, including authorization to release future health care information, except information to third party health care payors.

⇩ United Healthcare Release Of Information File

Form Attributes

Fact Detail
Voluntary Authorization The authorization for the release of information is voluntary.
Federal Privacy Laws Health information is protected under Federal Rules, including Title 45 of the Code of Federal Regulations, Parts 160 and 164, and Title 42 of the Code of Federal Regulations, Chapter I, Part 2.
Re-disclosure Warning Once disclosed, information may not be protected if the recipient is not a health plan or health care provider.
Content of Health Information The health information may include records from various healthcare providers and could contain sensitive information such as drug and alcohol treatment, mental health, HIV/AIDS, and reproductive health data.
Condition of Benefits UnitedHealthcare cannot condition treatment, payment, enrollment, or benefit eligibility on the signing of this form, with limited exceptions.
Revocation The authorization can be revoked at any time, although revocation will not affect prior actions taken by UnitedHealthcare.
State-Specific Provisions Various states, including Arizona, California, Georgia, Illinois, Indiana, Iowa, Minnesota, Oregon, Virginia, and Washington, have specific provisions regarding the authorization form and its provisions.
Witness Requirement & Copy Some states require a witness signature (Illinois) or provide the patient the right to receive a copy of the form (California, Georgia).

How to Fill Out United Healthcare Release Of Information

Filling out the United Healthcare Release of Information form is a crucial step in managing your health care, as it allows specific personal health information to be shared with designated individuals or organizations. This process can facilitate the coordination of care, the administration of benefits, or compliance with legal requests. Carefully completing this form ensures that your data is handled according to your preferences within the bounds of federal and state regulations.

  1. Enter the Member’s Name, Date of Birth, Member or Subscriber ID#, and Chart # at the top of the form.
  2. Provide the Member’s Street Address, including City, State, and Zip Code.
  3. Read the authorization statements that explain your rights and the purpose of this authorization form.
  4. Under the authorization section, specify the Name, Address, City, State, Zip, and Phone Number (with Extension if applicable) of the individual or organization authorized to receive or disclose your health information.
  5. Check the appropriate boxes to indicate the Description of individually identifiable health information to be received or disclosed. Select from options like All Treatment Plans, Claims, Progress Reports, etc., or specify another category under Other.
  6. Select the purpose of this authorization by checking the relevant box(es), such as Benefit Management, Claims Administration/Payment, or any other specified purpose under Other.
  7. Fill in the dates of records to be disclosed, specifying a From and To date in (MM/DD/YYYY) format.
  8. Determine when the authorization will expire either by specifying an expiration date or by defining an event that will end the authorization. Note the special instruction for Illinois residents.
  9. Sign and date the form in the provided spaces. If applicable, a minor member’s signature may also be required, along with the print name and relationship to the member for any legal guardian or member’s representative. Witness signatures are required for Illinois residents and encouraged for all for added validation, with specific provisions for California and Georgia residents related to form copies and inspection rights.
  10. Instruct California and Georgia residents to indicate whether they have requested and received a copy of this form.
  11. Review the form for accuracy, ensuring all information is complete and correct.
  12. Return the completed form to the UnitedHealthcare Customer Service Privacy Unit at the provided address, keeping a copy for your own records as suggested.

By accurately following these steps, you ensure that your health information is managed according to your wishes, enhancing your healthcare experience while protecting your privacy. Remember to consider the state-specific provisions that may apply to your situation, which are noted at the end of the form, as they can introduce additional requirements or rights related to the authorization process.

Common Questions

What is the United Healthcare Release of Information form used for?

The United Healthcare Release of Information form is a document that allows the disclosure of personal health information by UnitedHealthcare to designated persons or organizations, or from designated persons or organizations to UnitedHealthcare. This can include information such as treatment plans, claims information, attendance records, eligibility benefits, and more. It is commonly used for purposes like managing treatment and services, benefit administration, claims administration/payment, and compliance with legal processes.

Is signing the United Healthcare Release of Information form mandatory for receiving treatment or benefits?

No, signing this form is voluntary. Your decision to sign or not sign the form does not condition your treatment, payment, enrollment, or eligibility for benefits. However, there might be exceptions related to eligibility or enrollment determinations before being enrolled in a plan, and for health care provided solely for creating information for disclosure to a third party.

How can I revoke a previously given authorization?

You can revoke your authorization at any time by notifying UnitedHealthcare in writing. It's important to note that the revocation will not affect any actions taken based on your authorization before UnitedHealthcare received your revocation notice.

Who can I authorize to receive or disclose my health information?

You can authorize any individual or organization by mentioning their name and contact details on the form. This could include family members, healthcare providers, or legal representatives, depending on your specific needs and preferences.

What types of health information can be disclosed with this form?

The form allows for a broad range of health information to be disclosed, including drug and alcohol information, mental health details, HIV/AIDS status, psychotherapy notes, reproductive health, and sexually transmitted disease information, among others. You can specify the scope of information you're comfortable sharing.

For what purposes can my health information be used or disclosed?

Health information can be used or disclosed for various purposes, including but not limited to benefit management, administration of worker's compensation claims, claims administration/payment, administration of disability claims, employer mandated treatment or referral, and in response to a subpoena or other legal processes.

When does the authorization expire?

The authorization will expire on a specific date mentioned by you, or once a certain event you specify occurs. It's crucial to state a clear expiration date or event to ensure that your information is not used or disclosed beyond your preferences. Specific states may have additional requirements or provisions for the expiration of authorization.

Are there any special provisions for residents of specific states regarding the form?

Yes, there are state-specific provisions for Arizona, California, Georgia, Illinois, Indiana, Iowa, Minnesota, Oregon, Virginia, and Washington. These provisions can relate to how the request for medical records must be made, rights to receive a copy of the authorization form, expiration of the authorization, and requirements for witness signatures, among other details. It's important to review these provisions carefully to ensure compliance and to fully understand your rights and obligations under state law.

Common mistakes

Filling out the United Healthcare Release of Information form seems straightforward, but small mistakes can lead to big headaches. Here’s a list of common slip-ups made by individuals when completing this form:

  1. Not specifying the type of information to be disclosed, which can lead to incomplete release of necessary health records.
  2. Forgetting to check the purpose of the authorization, creating confusion about why the information is being requested.
  3. Omitting the dates of the records needed, potentially delaying the receipt of the right documents.
  4. Failing to fill out the expiration of the authorization correctly, which could either cut access too soon or leave it unnecessarily open-ended.
  5. Misunderstanding state-specific provisions and thereby not complying with local laws, particularly around witness signatures and special disclosures.
  6. Leaving the member’s information section incomplete, leading to uncertainties about whose records are being released.
  7. Missing the signature line, without which the form cannot be processed.
  8. Not providing the contact information for the person or organization receiving the information, causing delays in the transfer of records.
  9. Overlooking the check box for California and Georgia residents regarding the right to receive a copy of the authorization form.

Avoiding these mistakes can ensure a smoother process for everyone involved. It’s important to read the form carefully and review all sections before submission. Additionally, paying close attention to state-specific requirements can prevent unnecessary delays. Keeping a copy of the completed form for personal records is always a good practice.

Filling out the United Healthcare Release of Information form seems straightforward, but small mistakes can lead to big headaches. Here’s a list of common slip-ups made by individuals when completing this form:

  1. Not specifying the type of information to be disclosed, which can lead to incomplete release of necessary health records.
  2. Forgetting to check the purpose of the authorization, creating confusion about why the information is being requested.
  3. Omitter that is sought, potentially delaying the access to appropriate care or benefits.
  4. Failing to mention the dates from and to which the records apply, risking the omission of crucial information.
  5. Ignoring the section on the form's expiry date, which may render the authorization invalid sooner than expected or leave it unnecessarily valid for too long.
  6. Neglecting to fill in the details of the person or entity authorized to receive the information.
  7. Leaving out the member's signature or that of their legal representative, without which the form cannot be processed.
  8. Failing to choose the right option under the description of information to be disclosed, such as treatment plans, claims, or progress reports.
  9. Not checking the box to acknowledge receipt of a copy of this form, in states where this is required.

Attention to detail when filling out this form can prevent delays and ensure the right information is shared with the right people, at the right time. Keeping a copy for personal records is also a practical step.

Documents used along the form

When handling healthcare information, the United Healthcare Release of Information form is a critical tool in ensuring that your medical records are shared securely and according to your wishes. However, it's often not the only document you might need to provide or fill out during your healthcare journey. Understanding what other forms and documents might accompany this authorization form can help streamline your interactions with healthcare providers and insurance companies.

  • HIPAA Authorization Form: This form allows the disclosure of health information in accordance with the Health Insurance Portability and Accountability Act. It's used to specify which parts of your health record can be disclosed and to whom.
  • Medical Power of Attorney: This legal document designates someone to make healthcare decisions on your behalf if you're unable to do so. It's crucial for situations where medical decisions need to be made, and you're not capable of making them.
  • Advance Directive: Often prepared alongside the medical power of attorney, this document outlines your preferences for medical treatment should you become unable to communicate your wishes directly.
  • Consent to Treat Form: Before receiving medical treatment, patients are often required to sign this form, acknowledging that they agree to the proposed care plan.
  • Privacy Notice Acknowledgment Form: This document confirms that you've received a copy of a healthcare provider's privacy policy, outlining how your medical information might be used and shared.
  • Claim Form: Used to request payment or reimbursement from a health insurance provider, this form details the services received and their associated costs.
  • Disability Claim Form: If seeking disability benefits, this form is used to provide proof of disability and to request support from an insurance provider.
  • Request for Medical Records Form: This document enables the transfer of your medical records between providers or to yourself, ensuring you or your new doctor has access to your full medical history.
  • Pharmacy Prescription Form: A form your doctor fills out to prescribe medication, which you then take to a pharmacy to have filled.

Comprehending the purpose and necessity of these documents alongside the United Healthcare Release of Information form ensures your healthcare needs are met efficiently and with respect for your privacy. Always remember to keep a personal copy of these documents for your records and to review them carefully before signing. Your proactive involvement in managing your healthcare documentation can significantly impact the quality of care and the protection of your health information.

Similar forms

The Health Insurance Portability and Accountability Act (HIPAA) Authorization Form is closely related to the United Healthcare Release of Information form in several key ways. Both documents require an individual’s consent to share their protected health information, emphasizing the voluntary nature of this disclosure. They outline the specific types of information that can be shared and with whom, ensuring the individual's understanding that once information is shared, its protection is governed by the receiving party's privacy policies. These forms also inform the person signing about their right to revoke consent at any time, highlighting the control individuals have over their personal health information.

A Medical Power of Attorney (POA) shares similarities with the United Healthcare Release of Information form, particularly in the designation of authority to a third party. While a Medical POA grants broad authority to make healthcare decisions on behalf of an individual, the Release of Information form specifies authorization for sharing health information with identified parties. Both documents are pivotal in managing an individual's health care, especially under circumstances where the person cannot make decisions themselves. They ensure that trusted individuals or entities have the necessary information or authority to act in the best interest of the patient.

The Consent to Treatment form, often encountered in healthcare settings, parallels the United Healthcare Release of Information form in its foundational purpose of obtaining informed consent. This consent facilitates treatment procedures, sharing health information as part of the process, albeit in a more limited and immediate context. Similar to the authorization for release, consent forms make individuals aware of what they are agreeing to and grant permission for specific actions to be taken with respect to their health. Both documents underscore the importance of transparency and volition in the patient-provider relationship.

The Privacy Notice given to patients under HIPAA outlines how health information may be used and shared, drawing close parallels to the Release of Information form in intent and content. While the Privacy Notice serves as an overarching disclosure about the privacy practices of healthcare providers, the United Healthcare form is an actionable document through which an individual can specify permissions for the disclosure of their information. Both documents play critical roles in informing individuals about their rights and the handling of their health information, further emphasizing the safeguarding of patient privacy.

Dos and Don'ts

When filling out the United Healthcare Release Of Information form, navigating the details can be complex, but it's crucial to ensure your healthcare information is handled correctly. To make the process smoother, here are some do's and don'ts:

  • Do read the entire form before you start filling it out. Understanding all the sections upfront can help you provide accurate information.
  • Do verify your personal information, such as your Member or Subscriber ID#, to ensure there are no mistakes in identity.
  • Do clearly specify the type of information to be disclosed. This helps in maintaining privacy by only sharing necessary details.
  • Do indicate the purpose of the authorization precisely. Knowing why the information is needed can help protect your data.
  • Don't leave any required fields empty. An incomplete form may delay the processing of your request or lead to its rejection.
  • Don't forget to state the expiration date of the authorization or the specific event after which it should terminate.
  • Don't ignore the state-specific provisions that may apply to your situation, as these can affect the validity of your authorization.
  • Don't hesitate to ask for a copy of the form for your records once you've signed it, especially if you're a resident of California or Georgia where this is explicitly mentioned.

By following these guidelines, you can help ensure your information is handled correctly and your privacy is protected.

Misconceptions

In understanding the complexities and nuances of the United Healthcare Release of Information form, it is crucial to clarify common misconceptions that might confuse or mislead individuals who engage with it. Correcting these misunderstandings is essential to ensure individuals are fully informed about their rights and the implications of authorizing the release of their health information.

  • Misconception 1: Signing is Mandatory for Treatment. Many believe that they must sign the form to receive treatment. However, this document clearly states that signing is voluntary, and one's treatment, payment, enrollment, or eligibility for benefits generally cannot be conditioned upon signing, except under specific circumstances.

  • Misconception 2: It Offers Unlimited Access. Some might think that signing this form grants the recipient unlimited access to all health records indefinitely. In reality, the form allows individuals to specify the type of information and the dates of the records to be disclosed.

  • Misconception 3: Revocation is Complicated. Individuals often assume that once they have authorized the release of information, revoking it is a complex process. Contrarily, the form clearly mentions that authorization can be revoked at any time by notifying UnitedHealthcare in writing, albeit with the understanding that it will not affect actions taken before the revocation.

  • Misconception 4: Privacy is No Longer Protected Once Disclosed. While it's partially true that disclosed information might not be protected by federal privacy regulations if the recipient is not a healthcare provider or health plan, this overlooks the fact that other protections, such as state laws, may still apply. The key is understanding to whom the information is being disclosed.

  • Misconception 5: The Form Allows Disclosure to Anyone, Anywhere. Some may mistakenly believe that by signing, they are giving permission for their health information to be shared broadly. In reality, the form requires specification of the person(s) or organization(s) to whom the information is to be disclosed, limiting access to only those named entities.

  • Misconception 6: All Healthcare Information Can Be Released. The belief that all health information, including psychotherapy notes, can be released under this form is incorrect. The form specifically allows individuals to check the types of information to be disclosed, and certain sensitive information, like psychotherapy notes, often requires separate authorization.

  • Misconception 7: The Form Has an Indefinite Validity Period. Another common misconception is that once signed, the form is valid indefinitely. However, the form clearly requires the member or their representative to complete an expiration date or event which ends the authorization, ensuring it does not last forever.

It is of utmost importance for individuals to thoroughly review and understand each component of the United Healthcare Release of Information form before signing. This ensures their health information is handled according to their wishes and provides a clear understanding of their rights and protections under the law.

Key takeaways

Understanding the United Healthcare Release of Information form is crucial for anyone managing their healthcare information. Here are key takeaways to ensure the form is filled out accurately and effectively:

  • The form is designed to authorize United Healthcare to either receive or disclose your individually identifiable health information to specific persons or organizations you designate. This allows for the controlled sharing of your health information for purposes such as treatment management, claims administration, or legal processes.
  • Your authorization is voluntary but essential for facilitating the necessary sharing of information between healthcare providers, insurance plans, and other entities involved in your care or coverage.
  • The form contains protections under federal privacy regulations, such as the Federal Rules for Privacy of Individually Identifiable Health Information and the Federal Rules for Confidentiality of Alcohol and Drug Abuse Patient Records. However, once information is disclosed, it may no longer be protected by these regulations if the recipient is not a health plan or healthcare provider.
  • Special considerations are given to sensitive information, including mental health, HIV/AIDS, and substance use disorder records. Authorization for the release of such information may require additional steps or conditions to ensure compliance with applicable laws and regulations.
  • You have the right to revoke this authorization at any time. Revocation must be in writing, and it will not affect any actions taken before UnitedHealthcare receives the revocation. This provides a measure of control over your health information even after it has been shared.
  • State-specific provisions may apply to the signing and effectiveness of the authorization form. For example, some states require witness signatures, specify the form's expiration, or grant additional rights such as the ability to inspect the information disclosed. Familiarizing yourself with these provisions can ensure compliance with state laws and regulations.

Remember, maintaining a copy of the completed form for your records is important. It serves as evidence of your consent for the use and disclosure of your health information and can be helpful in case of discrepancies or misunderstandings regarding what information has been shared, with whom, and for what purpose.

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