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, or deliver it directly to our Member Services Offices. MMM Multi Health Member Services PO Box 72010 San Juan, PR 00936-7710 Fax: 1-844-990-4990 ServicioVital@mmmmhc.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.