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The customer or the customer’s legal representative may authorize someone else to act on behalf of the customer for the eligibility determination process. However, that person may not be able to authorize release of the customer’s confidential information. In this situation, the customer or legal representative can give permission to release information to AHCCCS by completing and signing any of the forms listed below:
Form |
Description |
Release of Information Authorization (DE-200) form |
Allows AHCCCS to ask for a broad range of information in order to determine eligibility. |
Permission to Release Information (DE-201) form |
Used to request specific eligibility information from a third party. |
Authorization for the Disclosure of Protected Health Information (DE-202) form |
Used to obtain a customer’s medical information. |
Authorization for the Disclosure of Psychotherapy Notes to the AHCCCS Administration (DE-222) form |
Used when a customer’s medical records contain psychotherapy notes that could affect the Pre-Admission Screening determination. |
Term |
Definition |
Legal Representative |
A legal representative is: · A person appointed by a court of law to represent someone else; or · The custodial parent of a minor child. |
Authorized Representative |
A person, or an organization, authorized by the customer, legal representative, or responsible relative of the customer to act on the customer’s behalf in the AHCCCS eligibility process. |
Programs |
Legal Authority |
All Programs |
42 CFR 431.300 through 307 45 CFR, Part 160 and Part 164 (subparts A and E) AAC R9-22-512 |