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Thank you. Your Authorization to Disclose Form has been submitted successfully. Please allow approximately 5 business days for your authorization to disclose information to reflect in the portal.

Authorization to Disclose Information Form

This Authorization to Disclose Information form is filled out when you (the Beneficiary, member, patient) want to grant another individual or organization access to your protected health information (PHI). This form is also filled out when a Sponsor wants to grant another individual (such as another parent or caregiver) or organization access to a minor dependent beneficiary's PHI. PHI is protected by the Privacy Act, the Health Insurance Portability and Accountability Act (HIPAA), state laws, and TriWest Healthcare Alliance (TriWest) policies and procedures.

If you have a Medical or Health Care Power of Attorney (POA) or other legal documents, which authorize a representative to have access to your medical records, you may provide the POA or legal documents and do not need to complete this form.

Beneficiary Information: In this section, enter the beneficiary's information. If you are a Sponsor completing this form for a minor, enter the minor's information in this section.

Identification of Individual or Organization: The information that you provide in the second section of this form tells TriWest to whom you want us to disclose your PHI. Per HIPAA, TriWest does NOT need authorization to share your PHI with a provider who is involved in your care.

Information to be Disclosed: In this section of the form, you select what information you are authorizing TriWest to disclose to the individual or organization you have named. You may choose to disclose your PHI with or without sensitive diagnosis.

Expiration: If you do not select one of the standard option periods or enter a date in the space provided, this Authorization to Disclose will be considered valid for one (1) year from the date you sign the form. Note: If the authorization is for a beneficiary currently under the age of 18, the authorization will expire on the beneficiary's 18th birthday. If the authorization is for a beneficiary currently under the age of 13, the authorization will exclude PHI regarding sensitive diagnosis beginning on the beneficiary's 13th birthday. The beneficiary will need to submit a new Authorization to Disclose Information form, authorizing access to their sensitive diagnosis PHI.

Agreement: Your rights regarding this Authorization to Disclose form are outlined in the "Agreement" section of the form. Please read it thoroughly. You are required to sign the document. If you are unable to complete the document, please refer to information below.

Personal Representatives: If you are a Personal Representative completing this Authorization to Disclose Information form on behalf of the beneficiary, a copy of the Medical or Health Care POA or other legal documentation appointing you as the Personal Representative must be attached to the form.

Privacy Act Statement: This information is protected under the Privacy Act of 1974 and shall be handled as "for official use only." Violations may be punishable by fines, imprisonment, or both.

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Date of Submission:
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Beneficiary Information

Identification of Individual or Organization

Who is TriWest authorized to disclose your PHI to? (This is most likely a family member or friend.) Per HIPAA, TriWest does NOT need authorization to share your PHI with a provider who is involved in your care.

I (Beneficiary) hereby authorize TriWest and its business associates to disclose my PHI to the individuals listed below:

Information to be Disclosed

Check all that apply - if no boxes are checked, sensitive diagnosis will not be included:

Expiration

This authorization expires: *

Representation

Please select if you are either the beneficiary or personal representative: *

Agreement

I understand that I may revoke this authorization at any time by submitting my revocation in writing to TriWest, except to the extent that action has already been taken in connection with this authorization or that applicable law requires its disclosure. I am aware that the recipient named above may also further disclose my PHI according to his/her/their policies and practices and that my PHI may no longer be protected by HIPAA. I further understand that TriWest may not condition treatment, payment, enrollment or eligibility for benefits on my signed submission of this authorization. I am entitled to keep a copy of this form for my records.

I agree and understand that by clicking the box below that it will constitute my electronic signature for the purpose of this Authorization to Disclose and that the electronic signature shall be the legal equivalent of my manual/handwritten signature. I understand that upon submission of this form with my electronic signature, TriWest shall act in accordance with the authorization above and applicable law and regulations.

Personal Representative

The beneficiary is unable to sign this form. I am the beneficiary's Personal Representative and I have included one of the following documents, which authorizes me to sign this form and to have access to the beneficiary's medical records:

*For Parents/Guardians:* If completing this form for your minor dependent child, please check the “Other legal documents” box, type “Parental Authority” in the space provided.

(Up to 25 attachments. Formats accepted are .doc, .xlsx, .pst, .pdf, .jpg, or .png no larger than 25 MB.)
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A valid phone number is required for all submissions. We will contact you about this request via this number.

Please enter a valid phone number.
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Fields with an asterisk ( * ) are required.
Date of Submission:

Beneficiary Information

Identification of Individual or Organization

Information to be Disclosed

Expiration

Representation

Agreement

Agreement Date

Personal Representative

(Up to 5 attachments. Formats accepted are .doc, .xlsx, .pst, .pdf, .jpg, or .png. No larger than 25MB.)

The Information collected with this form is subject to the Privacy Act of 1974 (5 U.S.C. 552A, as amended) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This information shall be considered for official use only and protected accordingly. Any individual responsible for unauthorized disclosure or misuse of this information may be subject to a fine of up to $50,000 and/or other sanctions as appropriate.