Form Mkt-496 - Bcbs Authorization For Health Information printable pdf download

AUTHORIZATION FOR

HEALTH INFORMATION

An Independent Licensee of the Blue Cross and Blue Shield Association.

AUTHORIZATION FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

This Authorization will permit Blue Cross and Blue Shield of Alabama and its business associates to receive, use and disclose

your health information for the purpose of determining your eligibility for enrollment and benefits under the Blue Cross and

Blue Shield of Alabama health contract, policy or plan for which you have applied ("Health Contract"). If you do not sign this

Authorization, your application for enrollment in the Health Contract will be denied.

Please read and complete the following:

Note:

A separate form for each Applicant, spouse and child must accompany the Health Contract application to be considered for health coverage.

Please list home address of each individual.

Applicant’s Name: _______________________________________________________________________________________

Last

First

Initial

Applicant’s Social Security Number: __ __ __ - __ __ - __ __ __ __

THE INDIVIDUAL AUTHORIZING DISCLOSURE OF HIS/HER PROTECTED HEALTH INFORMATION:

❏

If Applicant, check here and skip to address. (If spouse or child, please write the individual’s name)

Name: _________________________________________________________________________________________________

Last

First

Initial

Note:

Please include home address of each individual authorizing disclosure — may be different from Applicant’s address

Address: ______________________________________________________________________________________________ __

City: ___________________________________ State: ________ Zip: _____________ Telephone: _____- _____-_______ _____

Date of Birth: ____________________________ Social Security Number: __ __ __ - __ __ - __ __ __ __

YYYY

DESCRIPTION OF YOUR PROTECTED HEALTH INFORMATION TO BE DISCLOSED AND USED:

Any and all records related to (a) your medical history, treatment or other health care services rendered to you and (b) your

enrollment in or participation in any individual or group health plan or policy (“your Protected Health Information”) as may be

requested by Blue Cross and Blue Shield of Alabama or its business associates from time to time for the purposes described

below.

PERSON(S) AUTHORIZED TO DISCLOSE, RECEIVE AND USE YOUR PROTECTED HEALTH INFORMATION:

By signing this Authorization, you hereby authorize all of your past or present health plans, physicians, hospitals, clinics,

and other health care providers (and their respective business associates) to disclose your Protected Health Information to

Blue Cross and Blue Shield of Alabama and its business associates, as may be requested by Blue Cross and Blue Shield

of Alabama and its business associates from time to time, for the purposes described below.You also authorize Blue Cross and

Blue Shield of Alabama and its business associates to use and disclose your Protected Health Information for the purposes

described below.

DESCRIPTION OF EACH PURPOSE OF USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION:

You hereby authorize Blue Cross and Blue Shield of Alabama and its business associates to use and disclose your Protected

Health Information for the purposes of (a) determining your eligibility for enrollment in and/or your eligibility for benefits

the Health Contract; (b) for offering you coverage under the Health Contract; and/or (c) for notifying the Applicant of the Health

Contract application of whether you are denied coverage under the Health Contract and the reasons for any such denial.

DATE OF EXPIRATION OF THIS AUTHORIZATION:

This Authorization will expire three (3) years from the date that you sign this Authorization.

YOUR RIGHT TO REVOKE THIS AUTHORIZATION:

I understand that I may revoke this Authorization at any time by giving written notice to the address listed below. I understand that

revocation will not affect any action taken in reliance on this Authorization before you received my written notice of revocation.

Blue Cross and Blue Shield of Alabama

Attn: Customer Service

450 Riverchase Parkway East

Birmingham, Alabama 35244

MKT-496 (Rev. 8-2005) Front

Form Mkt-496 - Bcbs Authorization For Health Information

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