Arizona Authorization To Release Confidential Medical Information
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Authorization to Release
Confidential Medical Information
Please complete this Authorization to Release Confidential Medical Information form to authorize Health Net to disclose your confidential personal
information with the individual or organization you identify on this form. This Authorization is voluntary. We will not condition payment, enrollment in our
health plan, or eligibility for benefits on you giving this Authorization.
INFORMATION TO BE DISCLOSED
I authorize Health Net of Arizona and/or Health Net Life Insurance Company (Health Net) to disclose the following information: (please check all that apply)
__ Application, Enrollment, Eligibility Information
__ Transition of Care Information
__ Claims/Explanation of Benefit Information
__ Pharmacy Information
__ Prior Authorization
__ Medical Records
__ Premium Billing/Payment Information
__ Account Information
__ I authorize Health Net of Arizona to release information that may include record of drug, alcohol and/or