Consent to Release | Magellan in Wyoming

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 Medicaid
1-800-251-1270

Fields marked with an * are required.

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.

Wyoming Consent to Release

Last Name *

First Name *

Middle Initial

ID Number (SSN) *

Date of Birth *

Phone Number (###) ###-#### *

Address *

City *

State *

Zip Code *

Check One

I am the member
I have the legal right to act for this person

Part 2: Who can give out the PHI?

If you give your OK we can share your Health Information.

Magellan may give out your PHI. Magellan manages your High Fidelity Wraparound care coordination.

Magellan of Wyoming
PO Box 20520
Cheyenne, WY 82009
1-855-883-8740

Part 3 Who can the PHI be given to?

List who we can share your Health Information with. Please type the person’s first and last name or the name of the place that can have your PHI. We also need the phone number and address if you know it. Only list one person or one provider/facility in this section.

Name/Facility (please be as specific as possible *

Address *

City *

State

Zip Code *

Phone Number *

Fax Number *

Part 4 What PHI can we share?

We will only share the PHI that you OK. This OK includes facts about your medicine. It also includes facts about your mental health and/or your alcohol and drug treatment that are in your records. It does not cover psychotherapy notes that are not in your medical records.

Tell us the health information from your records that can be shared. Give the date and place if you can. *

If you give us your OK to share this kind of health information, tell us by checking the box (Choose all that apply).

High Fidelity Wraparound plans of care
CASII/ECSII and other evaluations used by Magellan
HIV/AIDS
Alcohol/Substance Abuse Records
Sexual/Physical/Mental Abuse

Part 5 Why are you giving out this PHI?

Please type why you want us to share your Health Information. * *

Part 6 When does my OK end?

Please type the date or event you want us to stop sharing your Health Information. Your OK will end when you tell us it does. Tell us when you want your OK to end:

My OK ends on this date or one year from now*

My OK ends when this happens

(It can be something like "you can share my medical records this one time"

If you do not tell us when your OK ends, then we will end your OK in one year from when you sign. After one year, we will need a new OK.

Part 7 Your rights and important facts

Please read this part of the form slowly. It talks about your rights and other important facts.
Giving your OK is up to you. You do not have to share your information.
You do not have to OK this paper. You will still get benefits and treatment.
You can take back your OK. You must tell us in writing. Mail it to: Magellan Behavioral Health of Wyoming, PO Box 20520, Cheyenne, WY 82003-0520.
What if you take back your OK? This will not take back the PHI that we have already shared. But, we will not share any more of your PHI.
If we share your PHI with the people or agencies that you named, they may share it with others. Not everyone has to follow privacy rules.
You have a right to get a copy of this signed OK. If you need another copy, call Magellan at (800) 424-6259.
If you do not understand, or have questions, we can help. Call Magellan at (800) 424-6259.

Part 8 Signature of member

Please type your name to say it is OK to share your Health Information.I give my OK to share the information listed on this paper.

Signature of Member *

Date

Please type your name, address and phone number to say it is OK to share the Member’s Health Information.Authorized Representative means you have legal proof that you can act for this person. A representative signs for a person who cannot legally sign on his or her own. If the Member is less than 18 years old, a parent or guardian should sign for the minor.If you have legal proof that you can act for this person, please send us that proof by clicking the button below, then select the document, then click ‘Open’. You may also mail it or fax it to Magellan at the address or fax number listed after you click ‘Submit’ below.

You should get a copy of this signed form. Remember, protected Health Information (PHI) means information about your health in the past, present or future. It includes facts like your address and date of birth. A full definition of PHI is at 45 CFR §160.103.

NOTICE TO ANYONE OTHER THAN THE MEMBER

This information has been disclosed to you from records the confidentiality of which may be protected by federal and/or state law. If the records are protected under federal regulations on the confidentiality of alcohol and drug abuse Member records (42 CFR Part 2), you are prohibited from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains, or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse Member.When you click ‘Submit’, your OK will be sent to the same person at Magellan who would receive the form if you mailed it to the address listed above. We will only give out the PHI that you OK. And, we will only give it to the person or place that you list in Part 3. Your information is safe and secure.