Authorize Release of Protected Health Information (PHI)

Your privacy is important to us. In accordance with state and federal laws, we don’t share protected health information (PHI) without your consent. Use these forms to authorize the release of PHI to a third party. The form you use depends on the type of policy you have.

For individual, family and small group plan members

Did you purchase your plan directly from us or through the Federally Facilitated Marketplace (FFM)? Or do you have coverage through a small employer (2 – 50 employees)? Use one of these forms:


For employees of businesses with 50 or more employees

Is your coverage through an employer with 50 or more employees? Use this form:


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