Health Insurance Portability and Accountability Act (HIPAA) Authorization Form – Beneficiary Verification

Please complete the fields below with your member information. After we verify your information, you will complete the HIPAA Authorization Form to specify how and with whom CareSource® MyCare Ohio (HMO D-SNP) may share your Protected Health Information (PHI).

Secure

First Name:

Last Name:

Beneficiary ID:

Please enter your full CareSource MyCare Ohio 11-digit member ID number

Date of Birth:

Medicare Claim Number:

CSMV-TRICARE-M-3934155