Form 391 C - Designation Of An Authorized Representative Form - Highmark Blue Shield - Pennsylvania
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1
2
3Designation of an Authorized Representative
This Section To be completed by the Customer Service Representative
Only
To: (
)
check one
Member Grievance and Appeals
Member Grievance and Appeals
P.O. Box 2717
P.O. Box 535095
Pittsburgh, PA 15230-2717
Pittsburgh, PA 15253-5095
Attention: Grievance Review Committee
Attention: Review Committee
Highmark Blue Shield
Highmark Blue Shield
P.O. Box 890178
P.O. Box 890174
Camp Hill, PA 17089-0178
Camp Hill, PA 17089-0174
Attention:Review Committee
Attention:Grievance Review Committee
Member Name: ___________________________________
Member's Date of Birth: _____/_____/________
Identification Number: _____________________________
Group Number: __________________________
Claim Number (
): ________________________
if applicable
Description of services/items denied: ____________________________________________________________
I, __________________________________ do hereby authorize Highmark Inc., to disclose the above
(Member Name)
information to ____________________________________ ,
(Name of Representative)
(
)
of _________________________________________________________________________________________
(Address of Representative)
(Telephone No. of Representative)
as my representative to participate in the:
Appeal
Complaint
Grievance
process on my behalf.
I understand that, if the persons or organizations I authorize to receive and/or use the protected health
information described above are not health plans, covered health care providers or health care clearinghouses
subject to federal health information privacy laws, they may further disclose the protected health information
and it may no longer be protected by federal health information privacy laws.
I understand that Highmark may condition payment of a claim for specified benefits on my signing of this
authorization (other than for psychotherapy notes) to allow other covered entities to disclose protected health
information to Highmark that Highmark needs to determine payment of my claim.
Highmark Inc., its subsidiaries, affiliates, employees, officers, and physicians are hereby released from any
legal responsibility or liability for disclosure of the above information to the extent indicated and authorized
herein.
If you are consenting to permit your health care provider to file an Act 68 Grievance on your behalf,
please also complete and sign page three (3) of this form.
Page 1
391 C 9/04
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