TotalCare (HMO D-SNP) Authorization for Release of Protected Health Information (PHI) Form

Providers and community partners can use this form to request that the Alliance release information related to a TotalCare member that is considered to be protected health information (PHI). The form is available in English, Hmong and Spanish.

The TotalCare document listed below can be viewed or downloaded as a PDF. To view and print it, you must have Adobe Acrobat Reader.

Click image below to open PDF file: