Healthcare Information Non-Disclosure Request Form (Page 2 of 2) in pdf

Healthcare Information Non-Disclosure Request Form Page 2

Alternate Address: _____________________________________________________________

City: __________________________________________ State: ______ ZIP: _____________

□

Alternate telephone number at which to be contacted: (

) ______ - ___________

D. INFORMATION NOT TO DISCLOSE

Check which types of PPI you do not want disclosed:

□

Alcohol/Chemical Dependency

Sexually Transmitted Disease (including HIV/AIDS)

□

Reproductive Health (including abortion)

General Health Information

□

Mental Health

Genetic Information

Note: To respond to your request, we may need to omit other types of PPI, as well.

E. PAYMENT

You must still pay for all costs related to your health plan. These include deductibles, copayments, coinsurance, and any non-covered

charges owed to providers.

F. DURATION OF THIS REQUEST

This request applies only to your current health plan. It stays in effect unless you notify us in writing. We may have already shared

your PPI with the person named in Section B before we received this request or while we were acting on it. We are not liable for these

disclosures.

IMPORTANT: We will deny or stop acting on a request that includes any minor children, if that request does not agree with court

orders or documents.

*Sign your name: ________________________________________

Date: _________________

*Print your name: _______________________________________

*If not the member, I am the

Parent

Legal Guardian

Holder of Power of Attorney/Legal Representative

If you are the legal guardian or holder of a power of attorney/legal representative for the member, please attach legal documentation.

When fully completed, fax or mail this form to:

Premera Blue Cross

P.O. Box 91102

Seattle, WA 98111-9202

Fax: 425-918-5592

For office use onlyDate received: ____________ Received by (initials):________

011710 (01-2012)

An Independent Licensee of the Blue Cross Blue Shield Association

Healthcare Information Non-Disclosure Request Form Page 2