Submit Form - AUDI 27 EN

AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INFORMATION
You can use this form to give permission to Aspire Health Plan to disclose your protected health
information. Please complete, sign and return this form to:
Aspire Health Plan
PO Box 5490
Salem, OR 97304

Member information (required)

Member last name *

Please provide a valid Member last name.

Member first name *

Please provide a valid Member first name.

DOB *

Please provide a valid DOB.

Member ID *

Please provide a valid Member ID.

Phone *

Please provide a valid Phone (e.g., 123-456-7890).

All personal healthcare information (includes all options

Please provide a valid All personal healthcare information (includes all options.

Health related information

Please provide a valid Health related information.

HIV test results

Please provide a valid HIV test results.

Mental health treatment information

Please provide a valid Mental health treatment information.

Billing and claims information

Please provide a valid Billing and claims information.

Provider/PCP information

Please provide a valid Provider/PCP information.

Enrollment or demographic information

Please provide a valid Enrollment or demographic information.

and/or changes and/or changes

Alcohol/drug treatment information

Please provide a valid Alcohol/drug treatment information.

Information above may be disclosed to the following individual(s):

1. Name of person who can receive information *

Please provide a valid 1. Name of person who can receive information.

1. Relationship (spouse, child, etc.) *

Please provide a valid 1. Relationship (spouse, child, etc.).

1. Date of birth *

Please provide a valid 1. Date of birth.

1. Telephone number *

Please provide a valid 1. Telephone number (e.g., 123-456-7890).

1. Address *

Please provide a valid 1. Address.

2. Name of person who can receive information

Please provide a valid 2. Name of person who can receive information.

2. Relationship (spouse, child, etc.)

Please provide a valid 2. Relationship (spouse, child, etc.).

2. Date of birth

Please provide a valid 2. Date of birth.

2. Telephone number

Please provide a valid 2. Telephone number (e.g., 123-456-7890).

2. Address

Please provide a valid 2. Address.

TODAY’S DATE *

Please provide a valid TODAY’S DATE.

SIGNATURE OF MEMBER (BENEFICIARY) *

Please sign SIGNATURE OF MEMBER (BENEFICIARY).

STREET ADDRESS *

Please provide a valid STREET ADDRESS.

ZIP *

Please provide a valid ZIP.

STATE *

Please provide a valid STATE.

CITY *

Please provide a valid CITY.