AHCCCS Patient Privacy (HIPAA) Forms

• Authorization For AHCCCS To Disclose Protected Health Information [PDF, 25KB]
  This form is intended for use by members who want AHCCCS to disclose their protected health information to another person or entity.
• Authorization for AHCCCS to Disclose Psychotherapy Notes [PDF, 25KB]
  This form is intended for use by members who want AHCCCS to disclose their psychotherapy notes to another person or entity.
• Authorization To Disclose Protected Health Information to AHCCCS [PDF, 25KB]
  This form is intended for use by members and applicants who want a doctor or other entity to give AHCCCS their protected health information.
• Authorization To Disclose Psychotherapy Notes To AHCCCS [PDF, 25KB]
  This form is intended for use by members and applicants who want a doctor or other entity to give AHCCCS their psychotherapy notes. This authorization remains in effect until the member's application for assistance through AHCCCS is withdrawn, denied, or when the member's AHCCCS eligibility ends.
•  Revocation of Authorization [PDF, 22KB]
  This form is intended for use by AHCCCS members who want to revoke (take back or cancel) their previously submitted authorization to release health information. This revocation does not apply to any information already released while the authorization form signed earlier was valid and in effect. The member may select one or several of the authorization forms to revoke or may select the ANY and ALL revocation option.