Member'S Protected Health Information (Phi) Request Form
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1
2MEMBER’S
PROTECTED HEALTH INFORMATION (PHI)
REQUEST FORM
You may give Blue Cross Blue Shield of North Carolina (BCBSNC) written authorization to disclose
your protected health information (PHI) to anyone that you designate and for any purpose. If you want to
authorize a person or entity to receive your PHI upon their request, please provide the information below.
Completion of this form is not a condition or requirement of coverage and will not change the way that
BCBSNC communicates with you. For example, we will continue to send explanation of benefits (EOB)
statements to you upon request. However, if your adult child calls BCBSNC to inquire about you, your
protected health information will not be shared with your adult child unless you have given BCBSNC
permission to do so by completion of this form.
Please print:
Member’s Name:
Member’s Date of Birth ______/ ______/ ______
BCBSNC ID Number
At my request, I authorize BCBSNC to disclose my Protected Health Information (PHI) to:
(If you choose, you may designate more than one person.)
Name:
Address:
Phone:
Relationship to Member:
Name:
Address:
Phone:
Relationship to Member:
We request that you provide the following information to the person you have authorized so that we may
verify the person’s identity and authority to receive your PHI: a) your ID number, b) your date of birth,
and c) your address.
I authorize BCBSNC to disclose only the following Protected Health Information to the person
designated above. (Check all that apply.)
Any information requested
Benefit information
Premium Payment Information
Explanation of Benefits information
All claims information
Enrollment information
All services from a specific health care provider (List provider’s name):
Other (Please list specific PHI):
Blue Medicare HMO and PPO Members: To authorize disclosure of your PHI about mental
health/substance abuse services, please call the Mental Health/SA telephone number on the back of your
ID card to request a separate authorization form.
I want the designated person to have access to my PHI until my policy expires OR until the
specified date of ______/______/______.
Continued on back
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