Member Consent For Release Of Protected Health Information
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1
2Member Consent for Release of
Protected Health Information
Use this form to allow Blue Cross* to share your protected health
information (also known as PHI) with an individual or organization.
A
Member who is giving consent
This form can only be used for one member. Please submit a separate form for each member.
Name __________________________________________________ Date of birth _______________________
Enrollee ID (number on ID card beginning with 1 to 3 letters) ______________________________________
Address _____________________________________________ Daytime phone _______________________
City _________________________________________________ State ___________ ZIP _________________
Protected health information to be shared
B
(check one)
Any and all information (including personal, health, demographic, claims, billing and
medical records)
Only limited information (such as for specific treatments, dates of service or billing details)
(please describe)____________________________________________________________________________
Please check below if you would also like to include any of the following
highly protected information (known as Super PHI):
Substance abuse records (including alcoholism)
AIDS or HIV treatment records
Mental health services (does not include psychotherapy notes)
Person or organization that may receive your information
C
Note: If information is shared with a person or organization that is not legally required to
obey privacy laws, the information may be shared with others and no longer protected.
Print first and last name for a person, and the most detailed name possible for an organization
(for example, hospital name and department).
Recipient’s full name ________________________________________________________________________
Please check the box below describing the person or organization’s relationship to you.
Family member
Friend
Doctor or health care provider
Other (describe) __________________________________________________________________________
Form continues on page 2.
* “Blue Cross,” “we” or “us” refers to Blue Cross Blue Shield of Michigan, Blue Care Network, Blue Care
Network Service Company, Blue Care of Michigan, Inc. or Blue Cross Complete of Michigan.
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