Giving your OK is up to you. You do not have to share your information.
You do not have to OK this paper. You will still get benefits and treatment.
You can take back your OK. You must tell us in writing. Mail it to: 333 W. Rossi Street, Boise, ID 83706. This will not take back the PHI that we have already shared. But, we will not share any more of your PHI.
If we share your PHI with the people or organization(s) that you named, they may share it with others. Not everyone has to follow privacy rules.
You should keep a copy of this signed OK. If you need another copy, please call Magellan at the phone number listed in (855) 202-0973 (TTY 711) below and we will send you a copy.
If you do not understand anything on this form or if you have questions, we can help. Please call (855) 202-0973 (TTY 711).
For substance use disorder facts: If the person or group listed above is a covered entity or business associate and gets your information for treatment, payment, or health care operations reasons, your information may be shared again by them as long as they follow the permissions in the HIPAA regulations, except for uses and disclosures for civil, criminal, administrative, and legislative proceedings against you.