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    MedData Release of Information 09 2020pdf

    Uploaded by

    tigerflysoul
    Heal your critical voice

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    MedData Release of Information 09 2020pdf

    Uploaded by

    tigerflysoul
    11 views1 page
    Heal your critical voice

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Heal your critical voice

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    11 views1 page

    MedData Release of Information 09 2020pdf

    Uploaded by

    tigerflysoul
    Heal your critical voice

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    _______________________________ ___________________ --

    ___________________________
    Name Date of Birth Social Security Number

    Release of Information
    Medical Assistance Purposes Only

    I, ___________________________________________ appoint MedData (MD) as my representative to assist


    me with my Medicaid or other medical assistance application, including requesting and representing me at an
    administrative fair hearing, or on appeal. To facilitate the application process, I state as follows:

    1. I request that any public medical assistance agency provide all information about my application to MD, including
    correspondence, information requests, interview dates, Spenddown notices, and notification of eligibility status.
    2. I authorize MD, in states where online Medicaid applications are accepted, to create a username and password and
    submit my medical assistance application online to the State agency for determination.
    3. I authorize the Social Security Administration and any other private or public agency or business, to disclose to MD
    any and all information requested by MD that may be necessary for the application process, including without
    limitation employment records, bank statements, financial records, child care costs, insurance information, identity
    documents (including social security number and photograph), and housing and utility information.
    4. I authorize any of my health care providers to disclose any and all of my medical and billing records (including records
    pertaining to AIDS/HIV, alcohol/drug abuse treatment, or behavioral/mental health services) to MD.
    5. I authorize MD and its affiliates, employees and agents:
    (1) to call or text me at any telephone number I have provided to MD or my health care provider, including any
    wireless/cell phone number
    (2) to leave answering machine or voice mail messages for me
    (3) to send emails to any email address I have provided to MD or my health care provider
    (4) to use pre-recorded/artificial voice or text messages and/or automated dialing devices (autodialers) in
    connection with any communications to me related to my medical care, services and accounts.
    6. I authorize MD to submit information obtained pursuant to this release to the appropriate medical assistance agency.

    This authorization, or any portion of it, may be revoked by sending written notification to [email protected].
    Revocation will not affect any action taken in reliance on this authorization before the revocation is received. This
    authorization shall be effective until one year after my medical assistance application is finally approved, denied or closed.
    I have the right to receive a copy of this form.

    ________________________________________________________________ _______________________
    Signature of Patient-Representative Date

    ____________________________________________ Relationship to Patient


    Refusing to sign this authorization will not impact my eligibility for benefits or services. .

    Copies or faxes of this release are acceptable. UPDATED 08272020

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