You can use this form if you represent someone and need access to their protected health information.

What you’ll need:

  • Their enrollee ID card
  • A printer to print the form
  • An envelope and postage to mail the form, or a fax machine. Each form includes instructions, a mailing address and a fax number.

If you have any questions, please contact us.

Request for Release of Member's Protected Health Information (PDF)