Please choose your state
This form lets you choose who you want to see to your personal information.
Please Note: The member listed below must sign this form.
How this works: This person listed above can help and act for you. They can help you with your claims and medical records. They can also help you with other information that may include medical records for:AlcoholismSubstance AbuseMental HealthPrescriptionsHIV StatusHIV Test Results
You will allow us to give this person your information until you tell us to stop. You can write to us at:email@example.com You understand that we (Magellan Health) are not responsible for how information is used by the person. We will not give any information after you tell us to stop. This is a copy and can be used as the original.
Type your name. This is your electronic signature.
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