Giving your OK is up to you. You do not have to share your information.
You do not have to OK this form. You will still get benefits and treatment.
You can take back your OK. You must tell us in writing. Mail it to Magellan Behavioral Health of Pennsylvania, Inc., 790 Township Line Road, Suite 120, Yardley, PA 19067
What if you take back your OK? This will not take back the PHI that we have already shared. But, we will not share any more of your PHI.
If we share your PHI with the people or organization(s) that you named, they may share it with others. Not everyone has to follow privacy rules.
You have a right to get a copy of this signed OK. If you need another copy, call Magellan at the phone number listed at the top of the form.
If you do not understand, or have questions, we can help. Call Magellan at the phone number listed at the top of the form.
Remember, Protected Health Information (PHI) means any information about your health in the past, present, or future. It includes facts like your address and date of birth. A full definition of PHI is at 45 CFR §160.103.