Consent to Release PHI Online Submission
Before you fill out this consent form, click on the appropriate link below to read through the instructions. If you still have questions on how to fill out this form, you can call us for help.
NOTE: If you are trying to request a copy of your (or your child’s) records, please fill out the “Member Right to Request Access to PHI Request Form” instead of this consent form. The “Member Right to Request Access to PHI Request Form” can be accessed under the Release Forms accordion here.
If you would like to fill out this form in Spanish, please fill it out here.