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

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Behavioral Health Administrators

Vendor Name	Address	Phone Number	Fax Number
LifeSynch (Formerly Corphealth)	LifeSynch, Inc. 1300 Summit Ave, Suite 600 Fort Worth, TX 76102 Attn: Privacy Office	800-890-8288	817-335-9100
Mental Health(MHNet)	MHNet, Inc. 9606 N. Mopac Expressway Suite 600 Austin, TX 78759 Director of Risk Management	888-830-7880	512-340-4295
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

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