HIPAA Authorization Form – Member 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 HAP CareSource™ MI Coordinated Health (HMO D-SNP) may share your Protected Health Information (PHI).

Secure

First Name:

Last Name:

Member ID:

Please enter your full HAP CareSource MI Coordinated Health 11-digit ID number

Date of Birth:

Medicare Claim Number: