Form 4361 Wa - Regence Authorization To Disclose Protected Health Information printable pdf download

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

Full Name________________________________________________________

Regence ID#______________________________ Date of Birth ______________

I authorize Regence BlueShield to disclose the following information:

Enrollment, eligibility, and benefit information

Claims, claim status, and claim history*

Medical records and diagnosis*

Premium and billing information

Psychotherapy notes*

Other__________________________

Regence BlueShield is authorized to disclose the information identified above to the following person(s) or entity(ies):

Name___________________________________________

Name_________________________________________

Address_________________________________________

Address________________________________________

Phone﴾_____﴿_____________________

The purpose of this disclosure is:

to assist me with my health plan

Other___________________________________

This authorization is valid for two years from the date of my signature or until _________________________

_______________________________________(cannot exceed two years from date of signature).

I may cancel this authorization at any time by sending written notice to Regence BlueShield, P.O. Box 1271, Portland, OR 97207-1271,

MS-C7A, Portland, OR 97207-1271. Cancellation of this authorization will not affect any actions taken by Regence BlueShield before

receiving my cancellation notice.

I understand completing this authorization is not a condition to receive treatment, payment, or eligibility. Regence BlueShield is not

responsible for any action taken by an authorized recipient of my protected health information. I am aware that an authorized recipient

may redisclose my information and the privacy protections provided by law may be lost.

►________________________________________________

_____________________________

Signed

Dated

If this authorization is signed by a person acting on behalf of another person, please complete the following and attach

documentation demonstrating your authority to act on behalf of another. (e.g., power of attorney, guardianship, conservatorship, etc.)

________________________________________ ﴾_____﴿_______________

________________________

Name of Personal Representative (please print)

Phone

Relationship

►______________________________________________________________

Signature of Personal Representative

*Note: Information about claims, medical records, diagnosis, and psychotherapy notes may contain sensitive data, including data related to treatment of chemical

Dependency, sexually transmitted disease, HIV/AIDS, mental health, and reproduction or contraception. DO NOT check the boxes authorizing the disclosure of

Claims, medical records, diagnosis, or psychotherapy notes if you do not want information relating to these sensitive conditions released.

Please return completed form to Regence: P.O. Box 1271 MS-C7A, Portland, OR 97207-1271

FORM 4361 WA (Rev.8/12)