- You may give written Authorization to disclose your protected health information (PHI) to anyone that you designate and for any purpose.
- If you wish to authorize a person to receive your PHI, please complete the information below.
- Unless this Authorization form is filled out, PHI will NOT be disclosed to anyone other than the patient.
- An Authorization MUST be filled out for each person you wish to receive your PHI.
- In addition, an Authorization MUST be completed by each of your adult dependents.
- Please note that in most cases an Authorization is NOT required for a parent or legal guardian to receive PHI on a minor child.
Maestro Claims Reimbursement / Provider Direct Pay Forms
Required Annual Plan Notices / New Hire Notices
2018 Salary Redirection Agreement