Who may find MADS-MR useful?
This form can come in handy to people who need an IMS Health Disability Evaluation Service disability determination.
What is MADS-MR Used For?
MADS-MR is an IMS Health Medical Records Release Form. It is used for getting medical information from the health-care provider. After collecting all the required data IMS Health Disability Evaluation Service makes a disability determination.
Is MADS-MR Accompanied by Other Forms?
This form should have a copy of the document that gives person the authority to act on behalf of the applicant or member, in case the form is not filled out by the applicant or member on their own.
In other cases MADS-MR does not require any attachments.
What Information should be Mentioned in MADS-MR?
While filling out MADS-MR you should provide the following information:
The first section consists only from one field that requires name of applicant or member to be provided. In the second section you should give an information about the health care provider. This includes provider's:
-
Name
-
Street address
-
City, state, ZIP
-
Telephone number
Section 3 is about the information health-care provider can share with the IMS Health DES. You should leave a description of other information about the treatment while in the blank space. You also can use checkboxes on the bottom part of the first page if you don’t want to share information about your AIDS/HIV status and drug or alcohol use.
The fourth part is a disclaimer to warn you about what happens if you either fill out you and don’t fill out this form.
The last section is for providing an information about the applicant/member. In this box you should provide:
-
Your signature
-
Your name
-
Address
In case this form is filled out by a person acting on behalf of the applicant or member, they should provide their signature, name and authority.
Where should I File MADS-MR?
After filling out the form you should file it to the IMS Health Privacy Office. You can find the post address on the bottom of the bottom of the second page. You will get back a copy of the signed Medical Records Release Form afterwards.
