Releasing HIPAA Information

If you want to, you can name another person that First Choice VIP Care Plus (Medicare-Medicaid Plan) may disclose your protected health information (PHI) to or discuss your personal information with.

If you want a friend, relative, doctor, or other  person to receive or discuss your personal information with us, complete the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Authorization for Disclosure of Health Information (PDF) or the Spanish Authorization for Disclosure of Health Information (PDF). The form gives us permission to discuss or disclose your PHI to the individual that you have named on the HIPAA form. It must be signed by you and by the person you have authorized. 

We will keep a copy of this form in your record, and the person you have authorized will be able to call us and discuss your PHI.

You can cancel or change this permission at any time.

If you need help completing this form, please call Member Services at 1-888-978-0862 (TTY/TDD 711), 8 a.m. to 8 p.m., seven days a week.