MLTC Policy 13.24(a)

Office of Health Insurance Programs

Division of Long Term Care

MLTC Policy 13.24(a): UPDATED Authorization for Release of Protected Health Information – Applicable to Partial MLTC, MAP, and PACE Plans

Date of Issuance: June 1, 2016

The purpose of this updated policy is:

  • To ensure that all Partial MLTC, MAP, and PACE Plans are consistently using a Health Insurance Portability and Accountability Act (HIPAA) compliant form when seeking authorization for release of Protected Health Information (PHI) for new enrollees.
  • To provide a response to existing MLTC plans that have been requesting multiple form options to meet plan–specific needs. This updated policy will provide clarification and flexibility to plans inquiring about which forms are acceptable for use going forward.

Effective upon release, all Partial MLTC, MAP, and PACE plans must use one of the following forms for new enrollees when seeking authorization of the release of enrollee´s (or prospective enrollee´s) protected health information:


New York Medicaid Choice/New York State Enrollment Broker uses the DOH–5032 form for new enrollees when conducting the Conflict–Free Evaluation and Enrollment Center (CFEEC) assessment.

This policy does not impact consent forms currently on file for existing enrollees. MLTC plans should assist the individual in understanding the content of the form. The authorization must be signed and dated and the enrollee must receive a signed copy. A copy must be maintained in the MLTC plan’s records. It is the plan’s responsibility to maintain forms with current effective dates on file for each enrollee throughout the duration of his or her enrollment.