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Authorization to Disclose Protected Health Information Use this form to authorize Tufts Health Plan* to use or disclose your protected health information. All fields are required. Incomplete or incorrect

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How to fill out member citystatezip

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Enter the city, state, and ZIP code of the member in the respective fields.

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Member citystatezip refers to the city, state, and zip code of a member or individual.

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Any entity or individual who is submitting a form or application that requires providing their city, state, and zip code.

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The information that must be reported on member citystatezip includes the city, state, and zip code of the member or individual.

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