MIPAA Compliant Release of Information Form:
Here you will find a HIPAA compliant release of information form. Because CCM is part of the administration of your self-funded program, most providers will not require that you complete this form to share information with us. However, some providers who may not be familiar with CCM may ask for a release. This release may be used. It is also helpful to fax a copy to us, so we can let them know there is a release on file should it get misplaced. You may fax this form to:

(607) 648-6444 (Health Plan Benefits)

(607) 648-3442 (Workers' Compensation and Disability Benefits)

We can accomplish almost anything within our ability if we but think that we can! - George Matthew AdamsCMDM