Authorization for the Release of Medical Information

By signing this form, I either wish to file a complaint, or I authorize a health care provider to file a complaint on my behalf, with the Health Education and Advocacy Unit (HEAU) of the Office of the Attorney General and/or the Maryland Insurance Administration (MIA).

I authorize the HEAU and/or the MIA to contact my health care providers, my insurance carrier, HMO, and other State or Federal government agencies, to obtain any medical records, mental health or substance abuse records, and/or insurance information related to the complaint filed by me or on my behalf. I authorize my health care providers and insurance carriers to release any medical records, mental health or substance abuse records, and/or insurance information relevant to the complaint filed by me or on my behalf to the HEAU and/or the MIA. I understand that my treatment, payment, enrollment, or eligibility for benefits under my health plan may not be conditioned upon whether I sign this Authorization. However, I understand that the HEAU and MIA will be unable to process my complaint if I fail to sign this Authorization.

If my complaint is referred to or filed with MIA, I authorize MIA to release my medical records to health care providers, my insurance carrier, HMO, independent review organizations, medical experts and other government agencies or contractors that may assist in the resolution of my complaint.

There is the potential for information provided to be subject to redisclosure in the process of investigating the complaint and pursuing any action required as a result of the complaint investigation, in which case the information may no longer receive privacy protection under Federal law. I understand that information about my experience may be used to develop statistical information on the health care marketplace in Maryland or to examine the quality of care of an HMO, but the confidentiality of my identity and medical records will be protected in accordance with Maryland and Federal law.

This authorization is valid for one year. It shall be automatically revoked once the complaint has been resolved. I understand that I may revoke this Authorization at any time by notifying the Health Education and Advocacy Unit or the Maryland Insurance Administration, if my complaint has been referred to or filed with MIA, which will provide me with a form to sign confirming my revocation. A copy of the revocation will be provided to each party to whom this Authorization was provided. I understand that the revocation will not apply to the extent that a health care provider and/or insurance carrier has taken action in reliance on this authorization.

I accept the terms of this agreement.

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PLEASE NOTE: All patients 18 years of age and over must sign this consent form themselves, unless they have a legal guardian, personal representative, are incapacitated or have otherwise delegated authority to complete this form. If so, the signer must submit written proof of guardianship, representation, incapacity or other delegation of authority with this consent form. A parent or guardian must sign on behalf of an unemancipated minor, except in certain circumstances. Where Maryland law allows a person under 18 to consent to health care treatment without the consent of a parent or guardian, only the signature of the patient is necessary.