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Authorization to Disclose Health Information

Notice to Member:

  • Completing this form will allow Superior HealthPlan 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 Superior 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 Member Services at the phone number on the back of your member ID card.
  • Superior 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 or if you have questions about this form, please call Superior.
  • To fill out this form and submit via mail or fax, please download the Authorization to Disclose Health Information Form (PDF). Once completed, you can mail or fax the form and any supporting documentation to:

Superior HealthPlan
ATTN: Compliance Department
5900 E. Ben White Blvd.
Austin, TX 78741

Fax: 1-833-205-1935

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

1. MEMBER INFORMATION:

2. I GIVE SUPERIOR HEALTHPLAN 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 EITHER (check one option below):

I GIVE SUPERIOR HEALTHPLAN 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

3. PERSON(S) OR GROUP(S) TO RECEIVE INFORMATION:

Note: Add more persons or groups in Section 7: ADDITIONAL INDIVIDUAL PERSON(S) OR GROUP(S) TO RECEIVE INFORMATION.

NOTE: If you are consenting to disclose any substance use disorder records to a recipient that is neither a third party payor nor a health care provider, facility, or program where you receive services 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 your substance use disorder records may be disclosed to your current and future treating providers at that recipient entity.

4. I AUTHORIZE SUPERIOR TO USE OR SHARE THE FOLLOWING HEALTH INFORMATION:

Please Note: Select the first statement to release ALL health information or select the below statement to release only SOME health information. Both CANNOT be selected.

I AUTHORIZE SUPERIOR TO USE OR SHARE THE FOLLOWING HEALTH INFORMATION *
all_of_my_health_information_except_options required *

5. AUTHORIZATION END DATE:

Using the calendar that populates, please enter the date you would like this authorization to end. If this field is blank, the authorization expires one year from the date of the signature below. DATE CANNOT BE THE CURRENT DATE OR THE AUTHORIZATION WILL BE DENIED.

6. SIGNATURE:

By typing in my name, I am attesting that I am the individual in question and am providing my consent for this authorization.
I confirm I am the member or the members Legally Authorized Representative (if member is younger than 18 years of age). required *

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

MAIL ANY SUPPORTING DOCUMENTATION TO SUPERIOR HEALTHPLAN, ATTN: COMPLIANCE DEPARTMENT, 5900 E. BEN WHITE BLVD., AUSTIN, TX 78741

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

section3_additional_individuals

NOTE: If you are consenting to disclose any substance use disorder records to a recipient that is neither a third party payor nor a health care provider, facility, or program where you receive services 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 your substance use disorder records may be disclosed to your current and future treating providers at that recipient entity.

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

By communicating with Superior HealthPlan via email, you give consent to receive information from Superior, which may contain Protected Health Information (PHI), to your email address. This consent is not required. Communication via email is not as secure as communicating via our secure member or provider portal. required *

If you agree to receive PHI information from Superior via email, please fill out the following field:

(Member [you], Parent, Caregiver or Legally Authorized Representative of Member)