Member Forms

Get Access to your Personal Health Information

Authorization of the Use and Disclosure of Protected Health Information (PDF)
Completing this form will allow MHS to share your personal health information with another company or individual that you name.

Revocation of Authorization to Use and/or Disclose Health Information (PDF)
Completing this form will allow you to revoke your approval of MHS sharing your personal health information with another company or individual that you previously named.

Contact the State to Report a Change (Address, Phone Number, etc.)

Call the Department of Family Resources (DFR) at 1-800-403-0864 or go to the FSSA Benefits Portal

If you would like this information in print, please contact MHS Member Services.