Form A46163 - Authorization For The Use Or Disclosure Of Health Information (Page 3 of 7) in pdf

Form A46163 - Authorization For The Use Or Disclosure Of Health Information Page 3

C. Signature

I have read this form and I understand and agree to its terms. I direct

Blue Shield of California to use or to disclose the Information to the noted

Recipient as directed above. I understand that once my Information is

disclosed, it could be re-disclosed by the Recipient and may no longer be

protected by privacy laws, including the federal Health Insurance Portability

and Accountability Act of 1996.

I understand that Blue Shield may not condition payment, enrollment in a

health plan, or eligibility for benefits on whether I sign this Authorization.

Signature

Date

Print name

D. Personal or legal representatives or guardians

If this form is signed by someone other than the Member or the parent of

a minor, such as a personal/legal representative, guardian, or executor,

you must also submit legal documentation showing your authority to act

on behalf of the Member (or the Member’s estate) to authorize the use or

disclosure of the Member’s health Information. Such documentation may

include, for example: 1) Durable Health Care Power of Attorney; 2) current,

valid documentation of court-ordered guardianship; or 3) other valid legal

documentation showing your authority to act on behalf of the Member

(or the Member’s estate).

Please also complete the following:

Representative’s name (print):

Relationship to Member:

Type of documentation submitted:

Keep a copy of this Authorization for your records.

Return the completed and signed Authorization form to:

Blue Shield of California Customer Service

P.O. Box 272540

Chico, CA 95927-2540

A46163 (10/16)

Form A46163 - Authorization For The Use Or Disclosure Of Health Information Page 3