Skip to Main content

Releasing Health Information

If you want to, you can choose another person that AmeriHealth Caritas VIP Care Plus may share or discuss your protected health information (PHI) with.

If you want a friend, relative, health care provider, or other person to receive or discuss your PHI, complete the Authorization for Disclosure of Health Information (PDF). The form gives us permission to discuss or disclose your PHI with the individual that you have chosen. The form must be signed by you and by the person you have chosen.

We will keep a copy of this form in your record, and the person you have chosen can call us and discuss your PHI.

You can cancel or change this permission at any time.

If you need help completing this form, please call Member Services at 1-866-533-5490 (TTY 711), seven days a week, 8 a.m. to 8 p.m.

H0192_001_WEB_455001