Form A46163 - Authorization For The Use Or Disclosure Of Health Information (Page 2 of 7) in pdf

Form A46163 - Authorization For The Use Or Disclosure Of Health Information Page 2

b. c Complete this section ONLY IF you did not check box 4(a) above,

and you wish to authorize disclosure of any of the following types

of Sensitive Information (check all that apply):

c Abortion

c Alcohol/substance

c Genetic

abuse

information

c HIV/AIDS

c Mental health

c Pregnancy

c Sexual, physical, or mental abuse

c Sexually transmitted illness

Note to parents/legal guardians of minors 12 years of age or older: You

may be unable to obtain or authorize the use or disclosure of certain types

of Sensitive Information about the minor without the minor’s own written

authorization. This may include the types of Sensitive Information listed above

as well as information regarding infectious diseases, rape/sexual assault, and

certain outpatient mental health counseling/treatment. If the minor is 17 years

of age or older, disclosure of information relating to domestic violence and

blood donations also requires the minor’s authorization.

5. What is the purpose of the requested use or disclosure of Information?

c The Information is about me and is to be used or disclosed at my request

c To resolve a claim dispute or appeal

c Other (specify):

B. Expiration and revocation

This Authorization will remain in effect for one year

from the date you sign it (below) unless a different

date is specified here:

______/_______/__________

You have the right to revoke this Authorization at any time by notifying

Blue Shield in writing. Revoking this Authorization will not affect Information we

use or disclose before we receive your revocation request. If this Authorization

is given by a parent or legal guardian on behalf of a minor, it will expire on

the minor’s eighteenth birthday.

A46163 (10/16)

Form A46163 - Authorization For The Use Or Disclosure Of Health Information Page 2