Form library
Managing your health
Confidential exchange of information
Use this form to allow your behavioral health provider to contact your medical doctor. This is important because you may receive medication from both providers, and some medicines can interact negatively. Your doctors need to know all the medicines that you’re taking and any medical issues you have to ensure you receive the best and safest treatment.
Managing your health care information
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule gives you the right to access, amend, share and monitor your health info. The forms on the next page will help you manage that info.
Release of information
This form gives permission to share your personal info with people you choose, like family, doctors and insurance companies. You’ll need to include all necessary documents and electronically sign the form. If you have an Illinois address, you can’t use this electronic form due to state law.
Wellness assessment
Complete this brief pre-visit questionnaire about your emotions and feelings. Take and review it with your clinician to help get services to best meet your needs.
Appointment of representative
A commercial member (or “patient”) may use this form to designate an authorized representative to act on their behalf regarding a grievance, payment appeal or denial of service appeal.