This form is used to release your protected health information as required by federal and state privacy laws. Your authorization allows the Health Plan (your health insurance carrier or HMO) to release your protected health information to a person or organization that you choose. You can revoke this authorization at any time by submitting a request in writing to the Health Plan (contact Member Services for further instructions). Revoking this authorization will not affect any action taken prior to receipt of your written request. To proceed with the electronic release of your Sensitive Information to another person or entity, please select continue.

Upload Your Authorization to Disclose Sensitive Health Information Form

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Member Correspondence
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Philadelphia, PA 19101
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