Authorization for the Use
or Disclosure of Health Information
A. Use this form to authorize Blue Shield of California, Blue Shield of
California Life & Health Insurance Company, and their business associates
(collectively “Blue Shield”) to use or to disclose your health information to
another person or organization.
1. Person whose information is to be disclosed (the “Member”).
Member name and address:
Subscriber ID number:
Date of birth:
2. Who is authorized to receive the Member’s information (the “Recipient”)?
Recipient’s name and address:
Recipient’s relationship to the Member:
3. What information may be disclosed to the Recipient? (Check one)
c Any or all information Blue Shield maintains. This may include information
relating to the Member’s medical care, diagnosis, providers, insurance or
benefit claims/payments, and/or financial/billing information. This does
not include Sensitive Information unless specifically approved below.
c Only the following Information, or types of Information, Blue Shield
maintains (specify):
4. Is the Recipient authorized to receive Sensitive Information?
c NO – PROCEED TO SECTION 5
c YES – Complete EITHER (a) or (b) below – you may not select both. I
specifically authorize the Recipient to receive:
a. c Psychotherapy notes – If you check this box, you may not check any of
the other boxes in section b. below. An Authorization for the release of
psychotherapy notes may not be combined with an Authorization for
disclosure of any other type of Information. PROCEED TO SECTION 5.
H0504_13_133 06252013
S2468_13_133 06252013
A46163 (10/16)
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