RR2024_UHC_ROI (03/24) MRACS36080OT_OS
Authorization for Release of Health Information
Please note:
1. To process your request faster, consider completing this form online:
https://www.uhc.com/member-resources/forms - scroll down to Tax, legal and
appeals forms and click on Power of attorney and release of information forms.
2. This authorization will be valid for one year. If you change your mind, contact us and
let us know. We will help you update your authorization to make sure it matches your
preference.
Follow these instructions to complete the form.
Member’s personal information
Write your full name, date of birth, address and member/subscriber ID in this section.
Who may get and share my information
Write the full name and address of the person(s) or organization(s) you are allowing to get
information from or share information with.
Type of information to be shared
Check one of the boxes. If you check the second
box, write what information we may share.
Purpose of disclosure
Check one of the boxes. If you check the second box, write the purpose of the release of
information.
Signature
To be valid, the form must be signed and dated. Illinois members also need the signature of
a witness.
Personal representative
If you have a guardian or court appointed representative, they must complete this section.
They will also need to attach a copy of their legal proof of authority.
MRACS36080OT_OS
Authorization for Release of Health Information
Please keep a copy of this form for your records.
Member’s personal information
Full name _____________________________________________________________________
Address ______________________________________________________________________
City _____________________________________ State _______ ZIP _________________
Member/Subscriber ID ________________________ Date of birth ____________________
I understand and agree that:
• This authorization is voluntary.
• My health information may be from third parties. This may include health care providers.
It may be these types of information:
o Medical records
o Substance abuse care
o Pharmacy
o HIV/AIDS
o Dental records
o Psychotherapy
o Vision care
o Reproductive care
o Mental health
o Communicable disease
• I may not be denied treatment or payment for health care if I don’t sign this form. I may
not be denied eligibility for health care if I don’t sign this form.
• My health information may be shared by the recipient. If the recipient is not a health
plan or provider, the information may not be protected by the federal rules.
• This permission will expire 1 year from the date I sign it. I may cancel it at any time. To
do so, I must tell UnitedHealthcare in writing. The revocation will not have an effect on
any actions prior to the date it is processed.
Who may get and share my information
I give permission for UnitedHealthcare and its affiliates to get from or share my health
information with:
Full name of person(s) or organization(s)
Full name of person(s) or organization(s)
MRACS36080OT_OS
Type of information to be shared
Check one of the boxes.
I authorize disclosure of all my health information. This includes these types of
information:
• Medical records
• Substance abuse care
• Pharmacy
• HIV/AIDS
• Dental records
• Psychotherapy
• Vision care
• Reproductive care
• Mental health
• Communicable disease
I authorize only the disclosure of the following information:
______________________________________________________________________
Purpose of disclosure
Check one of the boxes.
My health information is being shared at my request or at the request of my
representative.
My health information is being shared for this purpose:
______________________________________________________________________
Signature
______________________________________________ ____________________
Signature of member Date
______________________________________________ ____________________
Witness signature (
For residents of Illinois only
) Date
Personal representative
If you are a guardian or court appointed representative, you must attach a copy of your legal
authorization to represent the member.
Personal representative’s name __________________________________________________
Address ______________________________________________________________________
City _____________________________________
State _______
ZIP _________________
Phone number _______________________________
______________________________________________ ____________________
Signature of member’s representative Date
MRACS36080OT_OS
Ready to send the completed form?
Send the signed and completed form to:
UnitedHealthcare Community and State
PO Box 30753
Salt Lake City, UT 84130
Fax: 1-844-386-9286
Please keep a copy of this form for your records.
(For residents of California and Georgia only.
) I understand that I may see and copy the
aforesaid information if I ask for it. I may get a copy of this form after I sign it.
