AmeriHealth Caritas VIP Care will only share your protected health information (PHI) with someone that you authorize to receive the information or as allowed by law.

If you want a friend, relative, or other person to receive or discuss your personal information with us, complete the Authorization for Sharing Health Information (PDF). The form gives us permission to discuss or disclose your PHI to the individual that you have named on the form. It must be signed by you or your personal representative.

We will keep a copy of this form in your record, and the person you have authorized will be able to call us and discuss your PHI. 
*Note that this form does not provide the person you authorized to discuss your PHI with the ability to make health care decisions on your behalf.

You can cancel or change this permission at any time.

If you need help completing this form, please call Member Services at 1-844-964-4433 (TTY 711) 8 a.m. to 8 p.m., seven days a week. After hours, on weekends, and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

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