Provider Authorization Instructions
Member authorization allowing healthcare provider to use/disclose protected health information to Moda Health, Moda Health Plan, Inc and/or Moda Health Community Health, inc.
In order for this authorization to be valid, the following areas must be completed:
- Member Name (the person whose information is to be released)
- ID #
- Date of Birth
- Employer or Group Name
- Group #
- The member needs to authorize:
- Name of healthcare provider/entity disclosing information.
(May identify more than one provider on the authorization if desired.)
- To use and disclose a copy of my protected health information
- Moda Health Plan, Inc. provides Medical benefits, or
- Moda Health provides Dental benefits, or Moda Health Community
Health, Inc. or
- if the member has both coverages with Moda Health, they will need to check
both if they desire information from both plans to be shared.
- The purpose(s) for the disclosure. The individual should
indicate specifically the reasons that they are asking for information
to be shared. Examples of valid reasons are:
Release of all protected health information
- To discuss the payment of claim #D09348484.
- For release of all records related to my grievance/appeals process.
- To discuss claim payment concerns for all claims that were sent to Moda Health relating to my hospitalization of 10/01/03 to 12/15/03.
The most recent 2 years of protected health information (Choose
(If your selection is Specific Information, provide a detail of the information to be disclosed.)
I understand that the Healthcare Provider, listed above, needs my
specific authorization to release information pertaining to the items
listed below: HIV/AIDS, mental health information, genetic testing
information or drug/alcohol diagnosis. If the member desires that
we share information specifically related to those sensitive conditions,
the member must initial those lines. No initial indicates that no
information about the conditions(s) is to be shared.
Unless revoked, this Authorization will be in force and effect
until the following (check one) Either the date or
event box must be checked and filled out.
The authorization must be signed and dated by the individual
making the request in order to be valid. If a personal representative
of the member is signing on behalf of the member, the applicable information
must be included. Failure to fill out the following information
will result in a defective authorization:
- If the date box is checked, there must also be a valid present or
Example: (date of service is 06/01/04,
date authorization is signed is 07/01/04, expiration date of authorization
- The expiration date or event that relates to the individual or the
purpose of the use and disclosure
- If the event box is checked, then the event must also be listed.
Examples would include:
- Conclusion of Appeal II
- Independent Review of surgical request
- The name or other specific identification of the person(s) or
class of persons authorized to make the requested use or disclosure
- The purpose(s) or reason for requesting the provider records
- The signature of the individual and date
- If the authorization is signed by a personal representative of the
individual, a description of such representative's authority to act
for the individual and the required documentation (attached).
- Date or event - Please follow the guidelines.
Note: If you have additional information or concerns, please submit
this on a separate piece of paper and include it with the completed authorization
form. Please include your name and ID number on the correspondence.
Download the authorization for healthcare provider to release form
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For value-based provider programs, including Synergy, Summit, Beacon, Affinity, CPC+, and EOCCO
We have exciting news to share. ODS is changing its name to Moda Health.
Moda comes from the latin term "modus" and means "a way". We picked it because that's what we are here to do: help our communities find a way to better health.
Together, we can be more, be better.
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