Authorization for Use or Disclosure of PHI
How to authorize a third party to have access to your health information (PHI).
If you want a family member, friend, or someone close to you to have access to your health information, you must provide written authorization by completing the following form below, better known as the Authorization for Use or Disclosure of Protected Health Information (PHI Form).
This document must be completed in its entirety, following the instructions that appear on the first page of the form. If you have any questions, please call us at the Member Services number on your member identification card.
Send this form by mail, fax, or email, deliver it directly to our Member Services Offices.
Member ServicesPO Box 71114
San Juan, PR 00936-8014
Fax: 787-300-8014
mmm@mmmhc.com
Important Details
This authorization is valid for a maximum period of 2 years. You must select whether you want the authorization to expire in 2 years or on the date you want it to, which should be less than 2 years.
You must sign the document. If you do not know how to write, please put an “X” and have a witness sign the document.
If a person who is not the member (legal representative) signs this form on behalf of the member, please provide evidence of legal authority (e.g., power of attorney, legal guardianship).