Standard Authorization Form (Illinois) printable pdf download

Standard Authorization Form

To Use or Disclose

BlueCross BlueShield

Protected Health Information (PHI)

of Illinois

I. Individual

(Name and information

of person whose protected health information is being disclosed)

Name

Date of Birth

Group #

Identification/Subscriber #

Social Security Number

Address

City

State

ZIP

Area Code & Telephone Number

II. Authorization and Purpose:

I request and authorize Blue Cross and Blue Shield of Illinois to disclose my protected health information as described below. I

understand that if the person/organization authorized to receive and use the information is not a health plan or health

care provider, the disclosed information may no longer be protected by federal privacy regulations.

Persons/Organizations authorized to receive your information

Relationship

Purpose

Address

City

State

ZIP

III. Specific Description of Information to be Used or Disclosed (

Please Complete Parts A and B in this Section)

This Authorization CANNOT be used to disclose Psychotherapy Notes.

Release of Sensitive Protected Health Information Under State Law

You must check “yes” or “no” if you authorize the release of medical information, test results, records or communications specific to

(note: “yes” means this information is included in the categories you designate in Part B below) :

• Human Immunodeficiency Virus (HIV) or HIV/Acquired Immune Deficiency Syndrome

• Sexually transmitted or “communicable” diseases (includes hepatitis, as well as venereal

Yes

diseases);

• Drug, alcohol or substance abuse;

• Mental health or developmental disabilities (including mental retardation or similar disabilities,

for example, those attributable to cerebral palsy, autism or neurological dysfunctions); and

• Genetic testing.

Dates of Services

From:

To:

Release of Protected Health Information (check one or more)

Health Plan

Includes information contained in your benefit booklet (i.e., copayments,

Benefit

coinsurance, eligibility and other benefit information).

Information:

Claims

Includes information related to payment of your claims for service you received,

including pertinent information located on a claim form (i.e., billed amount,

general procedure descriptions claim payment or denial reasons, etc.).

Service

Includes any information related to pre-service, concurrent and post-service

Determination

decisions.

Information:

Premium

Includes information related to billing cycles, bank draft changes, etc.

Services from

Provider name:

(provider or

(Includes information related to services rendered by a specific provider or supplier.)

supplier):

Other:

(Specify other information that is not listed in one of the categories above.)

Rev. 09/28/07 – HCSC Regulatory Office

Page 1 of 2

Standard Authorization Form

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company

an Independent Licensee of the Blue Cross and Blue Shield Association

Standard Authorization Form (Illinois)

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