- TO:
- ALL FAMILY SUPPORT DIVISION OFFICES
- FROM:
- ALYSON CAMPBELL, DIRECTOR
- SUBJECT:
- AUTHORIZATION FOR RELEASE OF MEDICAL/HEALTH INFORMATION TO NURSING FACILITIES, IN-HOME NURSING CARE PROVIDERS, AND OTHER PROVIDERS OF MEDICAL SERVICES
DISCUSSION:
The purpose of this memorandum is to introduce expanded types of medical providers who participants may authorize to receive Income Maintenance case information. The title of the Nursing Facility Authorization Form (NFAF) introduced in Income Maintenance memorandum IM-26 AUTHORIZATION FOR RELEASE OF MEDICAL/HEALTH INFORMATION TO THE NURSING FACILITY WHERE THE MO HEALTHNET CUSTOMER RESIDES dated May 15, 2014 has been changed to the Provider Authorization Form (PAF), and its title is now “Authorization for Release of Medical/Health Information to Nursing Facilities, In-Home Nursing Care Providers, and Other Providers of Medical Services.” The signed PAF will allow staff to discuss participants’ case information with medical services providers of the participants’ choosing.
The participant is not required to sign this form. It is the choice of the participant or their representative to authorize release of information from their Income Maintenance case to medical providers. Signing the PAF does not create an authorized representative. Under the section “Your Rights with Respect to this Authorization,” the participant is given the option to bar FSD from disclosing his/her alcohol and drug abuse treatment records by initialing the box provided. Full authorization can be revoked by the participant through a written request to the medical provider and the DSS Privacy Officer at PO Box 1527, Jefferson City, MO 65102.
The PAF may be signed by the participant or his/her authorized representative, legal representative, or power of attorney. If the participant has a legal guardian or conservator, the form must be signed by the guardian or conservator.
When a PAF is signed, provide a copy of the form to the participant and/or the person who signed it on the participant’s behalf. Enter a comment on the Eligibility Unit Member Role (EUMEMROL/FM3Z) screen with comment titled “Provider Authorization Form.” The comment should state that the PAF has been signed, identify the provider authorized to receive information, and the person who signed the form, along with the date on which the authorization expires.
NECESSARY ACTION:
- Review this memorandum with appropriate staff.
ATTACHMENT:
AC/mh