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On June 20, 2024, UnitedHealth Group issued a press release offering an update on the Change Healthcare cybersecurity incident that occurred on Feb. 21, 2024. While the investigation to determine whose data is impacted is not yet complete, UnitedHealth Group has started the process to notify impacted customers and shared a website that provides additional information. UnitedHealth Group continues to offer credit monitoring and identity protection services, as well as a dedicated contact center to address questions. You can learn more about the support resources by visiting Change Healthcare Cyberattack Support and/or by reaching out to the contact center at 1-866-262-5342 with any questions. 

Authorization to Use and Disclose Health Information

Notice to Participant:

  • Completing this form will allow PA Health and Wellness to (i) use your health information for a particular purpose, and/or (ii) share your health information with the individual or entity that you identify on this form.
  • You do not have to give permission to use or share your health information. Your services and benefits with PA Health and Wellness will not change if you do not submit this form.
  • If you want to cancel this authorization form, send us a written request to revoke it at the address on the bottom of this page. A revocation form can be provided to you by calling Participant Services at the phone number on the back of your Participant ID card.
  • PA Health and Wellness cannot promise that the person or group you allow us to share your health information with will not share it with someone else.
  • Keep a copy of all completed forms that you send to us. We can send you copies if you need them.
  • If you need help, contact Participant Services at the phone number on the back of your Participant ID card.
  • To fill out this form and submit via mail or fax, please download the Authorization to Disclose Health Information Form (PDF). When finished, mail the form and any supporting documentation to: 

            PA Health and Wellness
            ATTN: Compliance Department
            1700 Bent Creek Blvd., Suite 200
            Mechanicsburg, PA 17050
 

PLEASE READ THE INSTRUCTIONS CAREFULLY AND COMPLETE THE FORM BELOW. INCOMPLETE FORMS CANNOT BE ACCEPTED.

1. PARTICIPANT INFORMATION:

2. I GIVE PA Health and Wellness PERMISSION TO USE MY HEALTH INFORMATION FOR THE PURPOSE IDENTIFIED OR TO SHARE MY HEALTH INFORMATION WITH THE PERSON OR GROUP NAMED BELOW. THE PURPOSE OF THE AUTHORIZATION IS:

(check one option below) required *

3. PERSON OR GROUP TO RECEIVE INFORMATION (add more Persons or Groups on next page):

4. I AUTHORIZE PA Health and Wellness TO USE OR SHARE THE FOLLOWING HEALTH INFORMATION (NOTE: Select the first statement to release ALL health information or select the below statement to releaseonly SOME health information. Both CANNOT be selected.)

All of my health information INCLUDING: Genetic information, services or test results; HIV/AIDS data and records; mental health data and records (but not psychotherapy notes); prescription drug/medication data and records; and drug and alcohol data and records (please specify any substance use disorder information that may be disclosed); required *

5. AUTHORIZATION END DATE:

Date this authorization ends unless cancelled. If this field is blank, the authorization expires one year fromthe date of the signature below.

6. PARTICIPANT OR LEGAL REPRESENTATIVE SIGNATURE:

By typing in my name, I am attesting that I am the individual in question and am providing my consent for this authorization.

If you are the Participant’s legal or personal representative, you must send us copies of relevant forms, such as power of attorney or order of guardianship.

MAIL COMPLETED AUTHORIZATION FORM AND ANY SUPPORTING DOCUMENTATION TO:

PA Health and Wellness, ATTN: COMPLIANCE DEPARTMENT
1700 Bent Creek Blvd. Suite 200 Mechanicsburg, PA 17050

 

NOTE: If you are consenting to disclose any substance use disorder records to a recipient that isneither a third party payor nor a health care provider, facility, or program where you receiveservices from a treating provider, such as a health insurance exchange or a research institution(hereafter, “recipient entity”), you must specify the name of an individual with whom or the entity at which you receive services from a treating provider at that recipient entity, or simply state that yoursubstance use disorder records may be disclosed to your current and future treating providers atthat recipient entity.

ADDITIONAL INDIVIDUAL PERSON(S) OR GROUP(S) TO RECEIVE INFORMATION:

Add Second Person/Group

Add Third Person/Group

Add Fourth Person/Group

Add Fifth Person/Group

Add Sixth Person/Group

Add Seventh Person/Group

Add Eighth Person/Group

Add Ninth Person/Group

Add Tenth Person/Group