This Authorization to Disclose form is flled out when you (the Benefciary, member, patient) want to grant another
individual or organization access to your protected health information (PHI). Your PHI is protected by the Privacy Act, the
Health Insurance Portability and Accountability Act (HIPAA), state laws, and TriWest Healthcare Alliance (TriWest) policies
and procedures.

If you have a Medical or Health Care Power of Attorney (POA) or other legal documents, which authorize a representative
to have access to your medical records, you may provide the POA or legal documents and do not need to complete this
form.

Identifcation of Individual or Organization
The information that you provide in the second section of this form tells TriWest to whom you want us to disclose your PHI.
Per HIPAA, TriWest does NOT need authorization to share your PHI with a provider who is involved in your care.

Information to be Disclosed
In this section of the form, you tell us what information you are authorizing TriWest to disclose to the individual or
organization you have named. You may choose to disclose your entire PHI maintained by TriWest or, in a written
description, you can specify the information you want disclosed to the designated individual or organization.

Expiration
If you do not select one of the standard option periods or enter a date in the space provided, this Authorization to Disclose
will be considered valid for one (1) year from the date you sign the form. Note: If the authorization is for a benefciary
currently under the age of 18, the authorization will expire on the benefciary’s 18th birthday.

Agreement
Your rights regarding this Authorization to Disclose form are outlined in the “Agreement” section of the form. Please read
it thoroughly. You are required to sign the document in the “Signature” space provided. If you are unable to sign the
document, please refer to “Personal Representatives” below.

Personal Representatives
If you are a Personal Representative signing this Authorization to Disclose form on behalf of the benefciary, a copy of the
Medical or Health Care Power of Attorney or other legal documentation appointing you as the Personal Representative
must be attached to the form. (See note regarding Medical or Health Care Power of Attorney above.)

Privacy Act Statement
This information is protected under the Privacy Act of 1974 and shall be handled as “for offcial use only.” Violations may
be punishable by fnes, imprisonment, or both.

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If flling out manually, use blue or black ink to complete this form.

Benefciary Information
First:

Middle:

Last:

Contact Phone:

          Last 4 of SSN:

DOD Benefts Number (DBN) or DOD ID Number:

Identifcation of Individual or Organization
Who is TriWest authorized to disclose your PHI to? This is most likely a family member or friend. Per HIPAA, TriWest does
NOT need authorization to share your PHI with a provider who is involved in your care.

I (Benefciary) hereby authorize TriWest and its business associates to disclose my PHI to the individuals listed below:

Name of Individual or Organization (#1):

Relationship to Benefciary:

Phone:

Address:

City:

State:

ZIP:

Name of Individual or Organization (#2):

Relationship to Benefciary:

Phone:

Address:

City:

State:

ZIP:

Name of Individual or Organization (#3):

Relationship to Benefciary:

Phone:

Address:

City:

State:

ZIP:

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Authorization to Disclose FormTRICARE is a registered trademark of the Department of Defense (DoD), DHA. All rights reserved.Authorization to Disclose Instructions

Information to be Disclosed
Check all that apply – if no boxes are checked, mental health will not be included:

Medical and Claims Information

Sensitive Diagnosis (includes substance abuse, mental health, reproductive health, sexually transmitted diseases,
physical/mental abuse, rape, and HIV. Note: Does not include psychotherapy notes.)

Scheduling of Appointments on Your Behalf

Other (please specify):

Expiration
This authorization expires (check only one box below):

One year from date form is signed. (This is the default if no option is selected.)

Fifty (50) years from date form is signed.

Other date (Date cannot exceed 50 years from date form is signed. Please specify below.):

Expiration Date (MM/DD/YYYY):

Agreement
I understand that I may revoke this authorization at any time by submitting my revocation in writing to TriWest, except
to the extent that action has already been taken in connection with this authorization or that applicable law requires its
disclosure. I am aware that the recipient named above may also further disclose my PHI according to his/her/their policies
and practices and that my PHI may no longer be protected by HIPAA. I further understand that TriWest may not condition
treatment, payment, enrollment or eligibility for benefts on my signed submission of this authorization. I am entitled to
keep a copy of this form for my records.

Benefciary Signature (If benefciary is unable to sign, please see next section.):

Signature Date (MM/DD/YYYY):

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Authorization to Disclose FormTRICARE is a registered trademark of the Department of Defense (DoD), DHA. All rights reserved.Authorization to Disclose Instructions

Personal Representative
The benefciary is unable to sign this form. I am the benefciary’s Personal Representative and I have included one of the
following documents, which authorizes me to sign this form and to have access to the benefciary’s medical records:

A Medical or Health Care Power of Attorney (POA)

Advanced Health Care Directives

Court Guardianship or Conservatorship papers

Other legal documents (please specify):

Benefciary’s Personal Representative Signature:

Printed Name of Benefciary’s Personal Representative:

Date (MM/DD/YYYY):

Submit Form
Fax to 877-875-1340 or mail the completed and signed form to the following address:

Privacy Offcial
TriWest Healthcare Alliance
P.O. Box 2585
Virginia Beach, VA  23450

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Authorization to Disclose FormTRICARE is a registered trademark of the Department of Defense (DoD), DHA. All rights reserved.Authorization to Disclose Instructions

