Form DE-202 Authorization to Disclose Protected Health Information to Ahcccs - Arizona

What Is Form DE-202?

This is a legal form that was released by the Arizona Health Care Cost Containment System - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is Form DE-202?
A: Form DE-202 is an authorization form used in Arizona to disclose protected health information to AHCCCS.

Q: What is AHCCCS?
A: AHCCCS stands for Arizona Health Care Cost Containment System. It is a program that provides health care coverage to eligible Arizona residents.

Q: Who needs to fill out Form DE-202?
A: Anyone who wants to authorize the disclosure of their protected health information to AHCCCS in Arizona needs to fill out Form DE-202.

Q: What is the purpose of Form DE-202?
A: The purpose of Form DE-202 is to give permission to health care providers to release an individual's protected health information to AHCCCS for the purpose of enrollment, eligibility determination, and coordination of benefits.

Q: What information is needed to fill out Form DE-202?
A: The form requires the individual's name, date of birth, AHCCCS identification number (if applicable), contact information, and a description of the specific protected health information that will be disclosed.

Q: Is the completion of Form DE-202 mandatory?
A: No, completion of Form DE-202 is voluntary. It is up to the individual to decide whether or not to authorize the disclosure of their protected health information to AHCCCS.

Q: How long is Form DE-202 valid?
A: Form DE-202 is valid for one year from the date of signature, unless a different period is specified by the individual.

Q: Can Form DE-202 be revoked?
A: Yes, the individual can revoke their authorization at any time by providing written notice to the health care provider or AHCCCS.

Q: Are there any fees associated with submitting Form DE-202?
A: No, there are no fees associated with submitting Form DE-202.