Releasing Health Information

If you want to, you can name another person that Keystone First VIP Choice may disclose your protected health information (PHI) to or discuss your personal information with.

If you want a friend, relative, doctor, or other person to receive or discuss your personal information with us, complete the Authorization for Disclosure of Health Information (PDF). The form gives us permission to discuss or disclose your PHI to the individual that you have named on the Health Insurance Portability and Accountability Act (HIPAA) form. It must be signed by you or your personal representative.

We will keep a copy of this form in your record, and the person you have authorized will be able to call us and discuss your PHI.

You can cancel or change this permission at any time.

If you need help completing this form, please call Member Services at 1-800-450-1166 (TTY 711), Monday through Friday, 8 a.m. – 8 p.m., from April 1 to September 30; or seven days a week, 8 a.m. – 8 p.m., from October 1 to March 31.