Authorization for Disclosure of Protected Health Information Form

Purpose: Complete and submit this form when you want to give another person access to your protected health information. For example, if you want someone other than yourself to regularly discuss your claims with Quartz, such as your child, spouse, or an insurance agent.

You can complete and submit the form online below. After submitting, you will be given the chance to download a copy of the form to save or print for your records.
If you prefer, a version of the form that can be filled out and printed or printed blank, signed, and then submitted by fax, mail, or email is available. (English | Español).
Questions? Please call Customer Service at (800) 362-3310.

How long does the authorization last?
Unless you specify otherwise on the form, the authorization will expire 24 months from the date signed. Note: If you reside in Minnesota, the form will expire one year from the date signed. If you reside in Illinois, it will expire 30 months from the date signed.

* Indicates Required Information

SECTION A: INDIVIDUAL AUTHORIZING USE AND/OR DISCLOSURE

First Name *

Last Name *

Member Number *

Street Address *

City *

State - 2 letters *

ZIP *

Date of Birth (MM/DD/YYYY) *

Telephone Number (###) ###-#### *

SECTION B: THE USE AND/OR DISCLOSURE BEING AUTHORIZED

Please check one: *

I authorize disclosure of all my health information including information relating to medical, pharmacy, dental, vision, mental health, substance abuse, HIV/AIDS, psychotherapy, reproductive, communicable disease, claims payment summary, claims correspondence, case or medical management, billing, payment, claims, enrollment, and health care program information.

I authorize only the disclosure of the following information (please specify):

Disclose Protected Health Information to:

Name of Individual/Organization *

Street Address *

City *

State - 2 letters *

ZIP *

Telephone (###) ###-#### *

Fax (###) ###-####

SECTION C: INDIVIDUAL’S SIGNATURE

Right to Refuse to Sign this Authorization: I understand that I am under no obligation to sign this form and that the Health Plan may not condition treatment, payment or eligibility for health care benefits on my decision to sign this authorization.

Right to Revoke this Authorization: I understand written notification is necessary to revoke this authorization. To obtain information on how to revoke my authorization, I may contact Customer Service (see above for contact information). I am aware that my revocation will not be effective until received by the Health Plan. I understand that my revocation will have no effect on disclosures made prior to the receipt of my revocation.

Redisclosure Notice: I understand once the Health Plan discloses my information based on this authorization, this information may no longer be protected by federal and state privacy standards and that my health information may be re-disclosed without obtaining my authorization.

Expiration: This authorization will expire 24 months from the date signed (one year if I reside in Minnesota or 30 months if I reside in Illinois), unless I specify an earlier date or event here:

I have had an opportunity to review this authorization form. I understand the content of this authorization form. By signing this authorization form, I am confirming that it accurately reflects my wishes. I am entitled to keep a copy of this form for my records. A copy of this form will be available to me upon my request. I can request a copy by contacting Customer Service at (800) 362-3310.

Your Signature/Your Personal Representative’s Signature: *

Parent/Guardian (Check this box if signing on behalf of a minor)

If a Personal Representative has signed this form, please attach appropriate documentation verifying legal authority, such as Guardianship or Power of Attorney for Finance Documents, if applicable.