Member Consent For Release Of Protected Health Information Page 2
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2Member Consent for Release of Protected Health Information, continued
Expiration and cancellation
D
This permission will expire (check one box only):
On this date (month, day and year, MM/DD/YYYY) ____________________________________________
When canceled, or upon my death
I understand that I can cancel this authorization at any time by submitting a written request on a
standard form, available online at or by calling the number listed on the back of my ID
card. I understand that cancellation will not apply to information that has been released by
this authorization.
Authorization and signature
E
I allow the use and disclosure of my protected health information as described above. This information
is being released at my request. I understand that my treatment, payment, enrollment or eligibility for
benefits does not depend on whether I sign this authorization.
Signature of member
___________________________________________________ Date _______________________
SIGN HERE
IMPORTANT: Please read the form over carefully and be sure you have included all necessary
information.
We cannot take additional information by phone, fax or email. If information is missing we
will have to contact you and request a new form.
Mail completed consent form to:
Blue Cross Blue Shield of Michigan
Mail Code X420
600 East Lafayette Blvd.,
Detroit, MI 48226
or fax to: 1-866-894-3101.
For additional assistance completing this form, call the number listed on the back of the member’s ID card.
Medicare Plus Blue, BCN Advantage and Prescription Blue are PPO, HMO, HMO-POS and PDP plans
with Medicare contracts. Enrollment in Medicare Plus Blue, BCN Advantage and Prescription Blue
depends on contract renewal.
Page 2 of 2
Y0074_F_PHIAuthForm FVNR 0615
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