Authorization for release of health information (FL Medicaid)

Florida Medicaid authorization for release of health information

I understand and agree that:

This authorization is voluntary.
My health information may contain information created by other persons or entities including health care providers and may contain medical, pharmacy, dental, vision, mental health, substance abuse, HIV/AIDS, psychotherapy, reproductive, communicable disease, and health care program information.
I will not be denied treatment if I do not sign this form.
I will not be denied payment for health (dental) care services if I do not sign this form.
I will not be denied enrollment or eligibility for health care benefits if I do not sign this form.
The recipient of my health information could disclose it to other parties who are not included in this authorization.
If parties are not health (dental) plans or health (dental) providers, then the information may no longer be protected by federal privacy regulations.
I may revoke this authorization at any time by calling Liberty Dental Plan at: 833-276-0850, by writing Liberty Dental Plan, P.O. Box 15149, Tampa, FL, 33684 or sending a fax to: 888-700-1727.
The revocation will not influence my dental care.

Who may receive and disclose my information:

I authorize Liberty Dental Plan and its affiliates to disclose my individual identifiable health information to the following person(s) or organization(s):

Please complete all fields. Fields marked as optional can be skipped.

Enrollee's full name

Enrollee's street address

City

State

Zip code

Full name of person(s) or organizations(s)

Address and/or phone number of person(s) or organization(s)

Type of information to be disclosed. Please check one.

I authorize disclosure of all my health information, including information relating to claims, dental, medical, pharmacy, vision, mental health, substance abuse, HIV/AIDS, psychotherapy, reproductive, communicable disease; or

I authorize only the disclosure of the following information:

Type of information

Purpose of disclosure. Check one:

My health information is being disclosed at my request or at the request of my personal representative; or

My health information is being disclosed for the following purpose:

Explain purpose

Signature of enrollee or representative

Please note: If you are a guardian or court appointed representative, you must attach a copy of your legal authorization to represent the enrollee

Last Date of Update 12/21/2021