I (Member Name) (Date of Birth)
authorize Beacon to disclose my health information to:
I CONSENT TO THE RELEASE OF THE HEALTH INFORMATION INITIALED BELOW:
All information in Beacon’s file
Only information checked below
I may revoke this consent at any time by notifying Beacon in writing to the address on my Member ID card. Consent for alcohol or substance use disorder records may be revoked by calling Beacon at the number on my Member ID card. *
Revoking my consent will not affect the rights of anyone acting in reliance of this consent prior to notice of the revocation. Unless revoked, this consent will expire on the following date, event or condition:
Otherwise, this consent will remain valid for twelve (12) months from the date this consent was signed.
Beacon will not condition payment, treatment, enrollment or eligibility for benefits on whether I sign this authorization. I understand that by not signing this form, the services provided to me by Beacon may be limited if benefits cannot be determined. I am aware that the information disclosed as part of this authorization may be re-disclosed and no longer protected under federal or state law.
* If you have any questions on how to revoke this authorization please contact firstname.lastname@example.org
** If you are signing as the Member’s Legally Authorized Representative, please attach the appropriate legal document(s) granting you the authority to do so (for example, Health Care Power of Attorney, Court Order, Guardianship, etc.)