Consent to Release Protected Health Information (PHI) Form – Use this form to allow us to share your health information.
Protected Health Information (PHI) means information about your health. Federal and state laws protect the privacy of your PHI. The laws say we cannot give anyone other than your doctors and the Division of Healthcare Financing — Medicaid your PHI unless you say it is OK. By submitting this online form, you give us your OK. Your information is safe and secure. We will only give out the PHI that you say we can share. And, we will only give it to the people or agencies that you list. Do you have any questions? We can help. Call Magellan Health Inc., (Magellan) at:
Wyoming Care Management Entity
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Please Note: No personal comments of any kind from the member or person completing the AUD Form are allowed in any section of this form.