Enhanced Care Management (ECM) Authorization for the Use and Disclosure of Health and Social Information | English

If you choose to do so, it must be done in writing and signed by you or your legal representative and sent to the following address: AltaMed Health Services, Attn: Health Information Management Director, 2040 Camfield Avenue, Commerce, CA 90040.

sumit authorization request via fax to (323) 720-5608 For inquiries or questions on authorization status, or in general, call the Altura Customer Services Department at (323) 417-7741 PATIENT INFORMATION

For Inquiries or questions on authorization status or in general call the AltaMed Customer Service Department at: (866) 880-7805. SUBMIT AUTHORIZATION REQUEST VIA FAX TO (323)720-5608 REQUEST DATE: _________________

Access your data electronically through the AltaMed Patient Portal. You may initiate a request over the phone. Email the form to [email protected] or fax (323) 201-3212.

Complete your renewal online at benefitscal.com, or return the renewal form you receive from your local Medi-Cal office. Don't lose your Medi-Cal benefits; make sure to complete the renewal before the due date printed on the notice.

Providers can access the CM Referral Form here. Post-Stabilization Hospital/Emergency Room attempting to provide telephonic notification for post-stabilization must call (323) 417-7741 to obtain authorization of post-stabilization care.

This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.

I hereby authorize AltaMed Health Services Corporation to disclose confidential sensitive health information to the person/organization named above: PURPOSE OF INFORMATION TO BE RELEASED: