Authorization To Use Or Disclose Health Information

The Privacy Rules of the Health Insurance Portability and Accountability Act (HIPAA) require that in order for us to release or obtain certain health information of plan Members protected under that law ("protect health information" or "PHI") for purposes other than matters pertaining to treatment, payment, or health care operations, or some public purposes, we need a written direction from you that contains the information you will need to provide in this form.