A Humana healthcare provider filling out behavioral health forms for a patient.

Behavioral Health Forms

Instructions for Behavioral Health Authorization to Release Information Form

Upon completion of the consent and release form, please submit to the behavioral health administrator listed below. To identify which behavioral health administrator to submit to, please refer to the member's ID card. If there is not a behavioral health administrator listed on the back of the card, call the 800 number on the card to verify the member's behavioral health administrator.

Authorization to Release Information Form
(45.5 KB) Download PDF
English

Behavioral Health Administrators

Vendor Name Address Phone Number Fax NumberFax
LifeSynch (Formerly Corphealth) LifeSynch, Inc.
2101 West John Carpenter Freeway
Irving, TX 75063
Attn: Privacy Office 		800-207-5101 866-771-0574
Mental Health (MHNet) MHNet, Inc.
9606 N. Mopac Expressway Suite 600
Austin, TX 78759
Director of Risk Management 		888-830-7880 512-340-4295512
Contact Behavioral Health Contact Behavioral Health Services
3740 East Southern, Suite 220
Mesa, AZ 85206
Attn: Privacy Officer 		800-309-2242 480-807-8268
PsychCare PsychCare
10200 Sunset Drive
Miami, FL 33173 		800-221-5487 800-370-1116-
Humana Humana Inc.
500 W. Main St., 9th floor
Louisville, KY 40202
Attn: Privacy Office 		See back of Member's Card Call number on back of card to request fax number