Consent to Release Protected Health Information (PHI) Form – Use these forms 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.
- Request for Personal Health Information – Please complete this form when you are asking us to share your child’s personal health information with someone else.
- Request Access to Personal Health Information – Please complete this form when you are asking us to provide you with your child’s personal health information.
Please mail the completed forms to:
Magellan of Wyoming
PO Box 1963
Evanston, WY 82931