Member Requested Authorization For Release Of Information Page 2
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1
2Member Requested
Authorization for Release
of Information
Member Information (person granting release of information)
Member Name ________________
Member ID
__________________
Date of Birth
___ / ___ / _______
Group Number __________________
I authorize Blue Cross to release the following information:
Address, date of birth, membership status
Claim Information for service with (provider name)______________________ for dates of service from
____________ to ____________
Premium information
Appeal information
Other
Note: Federal law says that Psychotherapy notes cannot be released using the same authorization form as
other records. In order to release Psychotherapy notes, you need to fill out a separate authorization form.
Psychotherapy notes
If this release involves a claim or an appeal, select where your claim notices and member payments are
sent:
I want Blue Cross to send all claim notices, appeal –related correspondence and member payments for
these claims to the person I have named below. I understand that by checking this box, this information
will not be sent to the address in my membership record.
I do not want Blue Cross to send all claim notices, appeal –related correspondence and member payments
for these claims to the person I have named below. These will be sent to the address in my membership
record.
Blue Cross may release this information to:
Name _______________________________________________________________
Address ________________________________________________________________
Phone Number ___ - ___ - _______
This person is my Authorized Representative
Purpose for this Release
Request of member or personal representative
For my Authorized Representative to handle my appeal concerning the claim information listed above.
Note: I understand that this authorization does not constitute an assignment of benefits.
Other, please specify ___________________________________________________
If the information relates to diagnosis or treatment of alcoholism or drug dependency, you must provide the name of
the treatment facilities or program(s):
_____________________________________________________________________________
If the information relates to diagnosis or treatment of alcoholism or drug dependency, I understand that the person(s) I
have named to receive the information must treat it as confidential. The information cannot be disclosed again without
another signed authorization from me. For all information other than diagnosis or treatment of alcoholism or drug
dependency, I understand that the person(s) I have named to receive information may not be subject to privacy laws.
They may be able to release the information and privacy laws may no longer protect it.
Right to Revoke - I understand that I may cancel this authorization in writing at any time, but it will not affect any
release of any information processed before I cancel it.
________________________________________________
___ / ___ / _______
Signature of Member
Date
______________________________________________________________
___ / ___ / _______
Signature of Parent or Personal Representative/Relationship to member
Date
This authorization is valid for one year after the date it is signed, unless an earlier expiration date is indicated here:
___ / ___ / _______
Note: You have a right to keep a copy of this notice after you sign it.
F7416R07 (08/08)
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