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South Privacy Forms

TRICARE South Region Authorization of Release for General Information

This Authorization to Disclose form is filled out when you, the beneficiary, want to grant another individual or organization access to your protected health information (PHI).

Return completed form (select best option):

Humana Military
HMHS Privacy Office
P.O. Box 740062
Louisville, Kentucky 40201-7462

Or fax to: 1-877-298-3407

TRICARE South Region Authorization for Release of Sensitive Information

The MCSC Operations Manual and state/federal law commonly state that information related to alcohol/drug treatment, abortion, venereal disease, and/or AIDS cannot be disclosed without written consent of the patient/beneficiary. In some instances, information related to mental health and pregnancy/birth control may also require written consent of the patient/beneficiary.)

Humana Military will follow all Federal and state laws and regulations that are more stringent. Return completed form (select best option) to Humana Military.

Humana Military Privacy Office
P.O. Box 740062
Louisville, Kentucky 40201-7462

Or fax to: 877-298-3407

Last Updated 9/3/2013