Form Mkt-496 - Bcbs Authorization For Health Information (Page 2 of 2) in pdf

Form Mkt-496 - Bcbs Authorization For Health Information Page 2

SIGNATURE OF INDIVIDUAL AUTHORIZING DISCLOSURE OF PROTECTED HEALTH INFORMATION;

I,_________________________________________________________, hereby certify to Blue Cross and Blue Shield

of Alabama that I am the individual described herein who is the subject of the Protected Health Information (or the individual's

Personal Representative*). I further certify that I have had full opportunity to read and consider the contents of this Authorization

and that all statements in this Authorization are true and complete in all respects.

I understand that my Protected Health Information may be re-disclosed by the person(s) I have authorized to receive and use

my Protected Health Information and that my Protected Health Information described herein may no longer be protected by

federal privacy laws.

Signature: _________________________________________________________________ Date: __________________________

Personal Representative Signature*: ___________________________________________ Date: __________________________

*If signed as a Personal Representative, you must describe your authority to act as the Personal Representative of the individual

who is the subject of the Protected Health Information (the Individual) by initialing one of the following:

__________ The Individual is an unemancipated minor child, I am the parent and have authority under applicable law to act on

behalf of the Individual in making decisions related to health care, and the health information described herein is relevant to my

personal representation of the Individual. Please Note: State laws vary regarding legal authority to make health care decisions for

your child. If you are unsure whether you have such legal authority, both you and your child must sign this Authorization.

__________ The Individual is an adult, unemancipated minor or emancipated minor, I am the guardian, attorney-in-fact or other

authorized representative and have authority under applicable law to act on behalf of the Individual in making decisions related

to health care, and the health information described herein is relevant to my personal representation of the Individual. Attached

is a copy of the legal document(s) that give me authority to act as a Personal Representative, such as letters of guardianship.

PLEASE RETAIN A COPY OF THIS AUTHORIZATION FOR YOUR RECORDS AFTER YOU SIGN IT.

MKT-496 (Rev. 8-2005) Back

Form Mkt-496 - Bcbs Authorization For Health Information Page 2