Authorization Disclose Personal Health Information - Trillium ...

(Medicaid) Authorization for Use and Disclosure of Protected Health Information (PHI)
The information Trillium keeps about you is called protected health information (PHI). This form gives
Trillium permission to use or disclose (give out) your PHI to the person or company you name. Please
see Section 6 of this form. Section 6 tells how this form is used.
Section 1: Your Medicaid member information
Member last name: First: Middle initial:
Member ID number:
Date of birth:
Check this box if you have both Medicare and Oregon Health Plan (Medicaid). This
authorization form will be used for both plans.
Section 2: Choose the PHI to be disclosed
Disclose: All of my PHI OR Only the items I have checked below.
Benefits information
Case or medical management records
Enrollment records
Customer Service records
Claims, billing and Explanation of Benefits information for the following date(s) of service or
medical condition:
Disclose only the following PHI:
IMPORTANT: The types of PHI listed below are protected by other laws. Trillium will only disclose the
types of PHI listed below if you give your permission. To give your permission, write your initials in the
box next to the PHI.
HIV/AIDS
Mental health information (except psychotherapy notes)
Alcohol/drug diagnoses, treatment, or referral
Genetic testing
MCA_DE02 Approved 08/27/2012 To receive this material in an alternate format or language
call: 1(877)600-5472 Page 1 of 3

Section 3: Enter the name of the person or company you want your information given to. Enter
the purpose for giving your PHI to this person or company. Enter the date or event when
Trillium should stop giving out your PHI to this person or company.
IMPORTANT: This authorization is good for one year from the date of signing, unless you give
another date.
Name:
Address:
Purpose of the use or disclosure:
Expiration date or event:
Name:
Address:
Purpose of the use or disclosure:
Expiration date or event:
Name:
Address:
Purpose of the use or disclosure:
Expiration date or event:
Section 4: Sign and date this form
Trillium has my permission to give out the PHI I listed on this form. This PHI may only be given out to
those named on this form. I know that my PHI may be shared by those named on this form and may
no longer be protected by law. Note: if you are signing as the member’s personal representative, you
must also include a copy of the legal papers showing your authority.
Member information:
Signature:
Printed name:
Date of signature:
Telephone number:
Street address: City: State: ZIP:
Personal Representative information:
Signature:
Printed name:
Date of signature:
Relationship to member:
Telephone number:
Street address: City: State: ZIP:
MCA_DE02 Approved 08/27/2012 To receive this material in an alternate format or language
call: 1(877)600-5472 Page 2 of 3

Section 5: Return this form
Please mail or fax this completed form, including this page to:
Trillium Community Health Plan
PO Box 11740
Eugene, Oregon 97440-1740
Attention: Privacy Officer
Fax number: 541-434-1291
Section 6: Important information
There are laws that tell when Trillium can use or give out your PHI without your authorization
(permission). The laws also tell when Trillium must have your permission to give out your PHI. Trillium
has a document called Notice of Privacy Practices (notice). The notice tells when Trillium can use or
give out your PHI without your permission. The notice also tells when Trillium needs your permission
to use or give out your PHI. If you need a copy of the notice, please call Trillium.
Note: You have the right to stop this permission any time, except on information that Trillium has
already given out. If you want to stop this permission, send a letter to Trillium. If you want to stop your
permission to give out records about your drug and alcohol programs, you don’t have to write.
Federal law says you can call and ask us to stop giving out your drug and alcohol information. After
you ask us to stop giving out the information to those listed on this form, no more information can be
given out.
Whether or not you let us give out your personal health information does not change your
membership, benefits, or the amount Trillium pays for your health services.
Personal representative information: Personal representatives signing this form must give Trillium
a copy of the legal papers showing their authority to sign this form. Representatives signing this form
for an agency that has custody must also give Trillium a copy of the legal papers showing their
authority.
HIV/AIDS, mental health, genetic testing, or alcohol/drug abuse treatment information: This
form must clearly tell Trillium if you want this type of information given out. This form must also show
the purpose for giving out this type of information.
Important information for minors (members under the age of 18): If you are under age 18, you
may give your permission for Trillium to give out:
• Your mental health or substance abuse information if you are age 14 or older.
• Any of your information about sexually transmitted diseases or birth control regardless of your
age.
• Your general medical information if you are age 15 or older.
Trillium Community Health Plan is here for you! If you have questions, call our Member Services team
toll free at 1(877)600-5472. TTY users call toll free at 1(877)600-5473.
MCA_DE02 Approved 08/27/2012 To receive this material in an alternate format or language
call: 1(877)600-5472 Page 3 of 3