Authorize a Representative
Your health care information on file with the State Health Plan is private. That information, also known as your Protected Health Information (PHI), can be released only with your permission.
At times, someone else might need to see your PHI. For example, a relative or caregiver might need to learn more about your health care history in order to care for you. Only you can give the State Health Plan permission to let someone else see your PHI. To do so, you must first complete and submit the following form to the State Health Plan.
PPO Authorization Form (PDF, 176KB)
Use this form to authorize someone else to access your Protected Health Information.
At times, someone else might need to see your PHI. For example, a relative or caregiver might need to learn more about your health care history in order to care for you. Only you can give the State Health Plan permission to let someone else see your PHI. To do so, you must first complete and submit the following form to the State Health Plan.
PPO Authorization Form (PDF, 176KB)
Use this form to authorize someone else to access your Protected Health Information.
