Authorization To Disclose Substance Use Disorder Records to AHCCCS Form – Behavioral Health

(For use by AHCCCS members/applicants who want a doctor or other entity to give AHCCCS and their health plan their substance use disorder records)

I understand that my substance use disorder records are protected under federal law, including the federal regulations governing the confidentiality of substance use disorder patient records, 42 CFR Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 CFR Parts 160,162, 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations.

I give my permission for my health care provider to disclose my substance use disorder records to AHCCCS, for the purpose of payment, medical review, case management, and care coordination.

Upon receipt of the records, AHCCCS may re-disclose them to the health plan I am currently served by for medical review, case management, and care coordination.

By signing this Authorization, I understand that:

• AHCCCS is required by state and federal law to keep confidential the information described above and may only use or disclose that information with my approval, for purposes directly related to the administration of the AHCCCS program, or as otherwise permitted or required by law. However, AHCCCS is prohibited from disclosing to any other person or entity, without my written permission, substance abuse information under the Federal Substance Abuse Confidentiality Requirements.
• I also understand that if I refuse to sign or revoke this authorization, AHCCCS may not be able to provide medical review, case management, and care coordination.
• I may revoke this authorization, in writing, at any time, by completing an AHCCCS "Revocation of Authorization. form, and sending it to:
  
  Arizona Health Care Cost Containment System
  Office of Legal Assistance
  Attention: Privacy Officer
  701 E. Jefferson, MD 6200
  Phoenix, AZ 85034
  Phone 602-417-4232
  Fax 1-602-253-9115

Once AHCCCS receives the revocation, this authorization will be revoked, except to the extent that AHCCCS has already taken action in reliance upon this authorization.

I have read the above and authorize the disclosure of my substance use disorder records as stated. This authorization will expire one year from the date of signing unless another date or specific event is given.

Specify other expiration date/event

This authorization will expire on:

Member or Member’s Representative