AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
Regence ID#____________________________ Date of Birth ______________
I authorize Regence BlueCross BlueShield of Oregon to disclose the following information:
Enrollment, eligibility, and benefit information
Claims, claim status, and claim history*
Medical records and diagnosis*
Premium and billing information
Regence BlueCross BlueShield of Oregon is authorized to disclose the information identified above to the following person(s) or
The purpose of this disclosure is:
to assist me with my health plan
This authorization is valid for two years from the date of my signature or until _________________________
_______________________________________(cannot exceed two years from date of signature).
I may cancel this authorization at any time by sending written notice to Regence, P.O. Box 1271, Portland, OR 97207-1271, MS-C7A,
Portland, OR 97207-1271. Cancellation of this authorization will not affect any actions taken by Regence BlueCross BlueShield of
Oregon before receiving my cancellation notice.
I understand completing this authorization is not a condition to receive treatment, payment, or eligibility. Regence BlueCross
BlueShield of Oregon is not responsible for any action taken by an authorized recipient of my protected health information. I am aware
that an authorized recipient may redisclose my information and the privacy protections provided by law may be lost.
If this authorization is signed by a person acting on behalf of another person, please complete the following and attach
documentation demonstrating your authority to act on behalf of another. (e.g., power of attorney, guardianship, conservatorship, etc.)
Name of Personal Representative (please print)
Signature of Personal Representative
*Note: Information about claims, medical records, diagnosis, and psychotherapy notes may contain sensitive data, including data related to treatment of chemical
Dependency, sexually transmitted disease, HIV/AIDS, mental health, and reproduction or contraception. DO NOT check the boxes authorizing the disclosure of
Claims, medical records, diagnosis, or psychotherapy notes if you do not want information relating to these sensitive conditions released.
Please return completed form to Regence: P.O. Box 1271 MS-C7A, Portland, OR 97207-1271
FORM 4361 OR (Rev.8/12)