This authorization form is for the purpose of allowing Physicians Health Plan to release protected health information at a member's request to third parties such as family members, group health plan administrators, or attorneys.

Here are some things to remember when completing the form:

• All blanks should be filled out.
• You must check the appropriate boxes to indicate items authorized for release. You may also write in specific information in this section. Mental health information and substance abuse information will not be released unless specifically indicated by checking the applicable boxes.
• The Personal Representative box at the bottom of the page needs to be completed only if an individual is requesting that someone else act for them, not only in receiving all requested information, but also in matters such as future authorizations for release of information.
• Form must be signed and dated. Signature must be that of the member, the parent or legal guardian of children under the age of 18, or the member's legal guardian or other duly designated personal representative.*

  *If the form is signed by an existing personal representative instead of the member, copies of appropriate documents (such as Power of Attorney) must accompany the authorization form.

  Authorization form

If you have any questions, please call Customer Service at (260) 432-6690, (800) 982-6257, or (260) 459-2600 for the hearing impaired. Completed forms should be faxed to (260) 432-0493, or mailed to Attn: Customer Service, Physicians Health Plan, 8101 W. Jefferson Blvd., Fort Wayne, IN, 46804.