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Provider Authorization Instructions

Member authorization allowing healthcare provider to use/disclose protected health information to ODS, ODS health plan, Inc and/or ODS 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 to:

ODS Health Plan, Inc. provides Medical benefits, or
ODS provides Dental benefits, or ODS Community Health, Inc. or
if the member has both coverages with ODS, 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:

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 ODS relating to my hospitalization of 10/01/03 to 12/15/03.

Release of all protected health information
The most recent 2 years of protected health information (Choose one)
Specific information
(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.

If the date box is checked, there must also be a valid present or future date.
Example: (date of service is 06/01/04, date authorization is signed is 07/01/04, expiration date of authorization is 07/01/05)
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 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:

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