Confidential Information Release Form - Hiv - Blue Cross Blue Shield Of Arizona printable pdf download

CONFIDENTIAL INFORMATION

RELEASE FORM - HIV

Use this form to let a person get your HIV-related information. Even if you don’t sign it, Blue Cross Blue Shield of

Arizona (BCBSAZ) will still pay your claims, sign you up for our plan and let you be eligible for benefits. This form

is not required.

I authorize BCBSAZ to give my HIV-related information (tests for HIV, AIDS or related illnesses) to:

Name: ____________________________________________________________________________________________

Street Address: _____________________________________________________________________________________

City, State, Zip Code: _________________________________________________________________________________

Reason for giving out the information: _____________________________________________________________________

_________________________________________________________________________________________________

This permission starts the day you sign this form. It will be good for 180 days. The person who gets your records may not keep them

private. If that happens, your records may not be protected by federal privacy laws.

You may tell us to stop sharing your records at any time. If you want us to stop sharing, write to us at: BCBSAZ Privacy

Office, Mail Stop C302, P. O. Box 13466, Phoenix, AZ 85002-3466. If you tell us to stop sharing, it will not change

what BCBSAZ shared before you told us to stop.

Member’s Name: ______________________________________ BCBSAZ ID Number: ____________________________

Member’s Signature: ___________________________________ Date Signed: __________________________________

Group Name (if this applies): ______________________________ Group Number (if this applies): _____________________

Representative’s Name*: ________________________________ Relationship to Member: _________________________

Representative’s Signature: _______________________________ Date Signed: __________________________________

* Attach a copy of the legal paper(s) that apply.

PleASe hAve A NOtAry SIgN the fOrM

State of _____________________________________________ County of ____________________________________

This form was signed before me on: _________________________

Notary Public: ________________________________________

My commission expires: _________________________________

you can get a copy of this form after you sign it. you may refuse to sign this form.

Please send us the filled out form.

Mail it to: BCBSAZ, Attention: enrollment, P.O. Box 13466, Phoenix AZ 85002-3466;

Fax it to: 602-864-4041 or Email it to:

Para obtener asistencia en Español, llame al (602) 864-4884 or (800) 232-2345 ext. 4884.

Kung kailangan niyo ang tulong sa Tagalog tumawag sa (877) 475-4799.

如果需要中文的帮助，请拨打这个号码 (877) 475-4799.

Dinek’ehgo shika at’ohwol ninisingo, kwiijigo holne’ (877) 475-4799.

Confidential Information Release Form - Hiv - Blue Cross Blue Shield Of Arizona