You can use this form when you want to let someone or some place see your psychotherapy notes, which are part of your protected health information.

What you’ll need:

• Your Subscriber ID card, also known as 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.

Authorization for Use and Disclosure of Psychotherapy Notes (PDF)