(For use by AHCCCS members/applicants who want a doctor or other entity to give AHCCCS and their health plan their substance use disorder records)
I understand that my substance use disorder records are protected under federal law, including the federal regulations governing the confidentiality of substance use disorder patient records, 42 CFR Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 CFR Parts 160,162, 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations.
I give my permission for my health care provider to disclose my substance use disorder records to AHCCCS, for the purpose of payment, medical review, case management, and care coordination.
Upon receipt of the records, AHCCCS may re-disclose them to the health plan I am currently served by for medical review, case management, and care coordination.
By signing this Authorization, I understand that:
Once AHCCCS receives the revocation, this authorization will be revoked, except to the extent that AHCCCS has already taken action in reliance upon this authorization.
I have read the above and authorize the disclosure of my substance use disorder records as stated. This authorization will expire one year from the date of signing unless another date or specific event is given.
Specify other expiration date/event
This authorization will expire on: