Form Cut6556-1e - Bcbs Authorization Form For Information Release printable pdf download

Form Cut6556-1e - Bcbs Authorization Form For Information Release

UTHORIZATION

ORM FOR

NFORMATION

ELEASE

You may authorize your insurer in writing to share your health information with a third party such as

an employer, lawyer, individual broker or unrelated party by completing and submitting this

authorization.

Please print neatly to ensure correct and prompt processing. We reserve the right to return

any illegible or incomplete form.

1) I, hereby Authorize: __________________________________________________

(Health Insurance Plan/Company)

2) To Release Information from the Records of:

(Complete a separate form for each member.)

Name: __________________________________________ Date of Birth: ________________

Membership Number: ________________________________________

Address: ___________________________________________________________

Home Phone: _______________________ Work Phone: _____________________

3) Information Authorized for Release:

(check all that apply)

_____ Claims/EOB Information

_____ Enrollment & Benefit Information

_____ Information pertaining to an Appeal

_____ Mental Health Records

_____ Alcohol & Substance Records

_____ Premium Payment Information

_____ Other: _______________________________________________________

(Please specify date of service and or provider name.)

4) Information may be Released to:

A. Name of Individual or Organization: ______________________________________

Address: ___________________________________________________________

City, State, Zip: ______________________________________________________

Telephone: _________________________________________________________

B. Name of Individual or Organization: ______________________________________

Address: ___________________________________________________________

City, State, Zip: ______________________________________________________

Telephone: _________________________________________________________

C. Name of Individual or Organization: ______________________________________

Address: ___________________________________________________________

City, State, Zip: ______________________________________________________

Telephone: _________________________________________________________

CUT6556-1E (7/08)

Form Cut6556-1e - Bcbs Authorization Form For Information Release