Authorization for Release of Information

You must complete this form to authorize Prime Therapeutics to share information about you with someone else.

Note: Under the law, an authorization for use or disclosure of psychotherapy notes cannot be combined with an authorization for other health care information.

Member Information (Person granting release of information)
*Required field

Member ID

First Name*

Last Name*

Date of Birth*

Month Day Year

Address*

Address Line 2

City*

State*

Zip code*

Group Number

By signing below, I authorize the release of prescription history and other medical information about me identified below (“My Information”) that is created or held by Prime Therapeutics LLC, as described in this form. My Information may include my name, address, date of birth, and plan membership status and information.

Prime Therapeutics, on behalf of my health plan, may release My Information to:

First name*

Last name*

Phone number*

Address*

Address line 2

City*

State*

ZIP code*

Fax

Purpose for this release* Purpose for this release*

At the request of the member At the request of the member
Other (please specify) Other (please specify)

If the information relates to diagnosis or treatment of alcoholism or drug dependency, we must have the name of the treatment facilities or program(s) where the member was treated.

256 characters only

I understand that the person(s) I have named to receive the information may be required under state or federal law to treat it as confidential if it relates to the diagnosis or treatment of alcohol or drug dependency. If protected by state or federal law, the person(s) I have named to receive the information may not share alcohol or drug dependency related information without another signed authorization from me. For all other information, I understand that the information may be released by the recipient to others (if not restricted by law) and no longer protected by privacy law requirements.

Right to Revoke

I understand that I may cancel this authorization at any time by sending a written request to Prime Therapeutics at the address included in the instructions above. A Revocation of Authorization form is also available for your convenience on the Prime website. The cancellation will not apply to any information used or disclosed in reliance on the authorization. I understand that if I choose not to sign this authorization or if I cancel this authorization, it will not affect my treatment, payment, enrollment or eligibility for benefits to which I am otherwise entitled.

This authorization is valid for one (1) year after the date it is signed, unless an early expiration date is indicated here:

Override Expiration Date

Month Day Year

Form must be signed by one of the following:

Member
Parent or legal guardian of a minor, except†if any of the following categories of information will be released:
- Pregnancy
- Sexually transmitted disease
- Alcohol or drug abuse
- Abortion
- Hepatitis B shot
- Mental illness of a minor

†For these types of records, please use the pdf version of the Authorization for Release of Information.

Member Electronic Signature
Parent or Personal Representative Electronic Signature

First name

Last name

Date

Month Day Year

I understand that by checking this box constitutes a legal signature confirming that I acknowledge and authorize Prime to process this Authorization for Release of Information.

First name

Last name

Date

Month Day Year

Relationship to member

I understand that by checking this box constitutes a legal signature confirming that I acknowledge and authorize Prime Therapeutics to process this Authorization for Release of Information.

Attach files

File formats supported are: .pdf only. A maximum of 3 attachments only can be attached (file size of each attachment cannot exceed 960kb).

Authorization for Release of Information

Right to Revoke

Member links

About Prime Therapeutics

Authorization for Release of Information

Right to Revoke

Member links

About Prime Therapeutics

Want to get home delivery service with only one click?

Want to get home delivery service with only one click?

Want to get specialty service with only one click?

Want to get specialty service with only one click?