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Authorization for Release of Personal & Health Information

Blue Shield of California and/or Blue Shield of California Life & Health Insurance Company (Blue Shield)

require specific written authorization for the disclosure of any personal and health information, beyond that

which is necessary to provide treatment, to facilitate payment, or to perform operations of the health plan

or insurer, to the extent permitted by law. Blue Shield will only disclose that information which is reasonably

necessary to achieve the purpose of the request for release.

1. I, the Undersigned, Authorize:

Blue Shield

2. To Release Information from the Records of:

Member Name:______________________________________________________________

Member Date of Birth: _______________________________ Subscriber #: _______________

3. Information Authorized for Release (check all that apply):

❑ Address Change

❑ Policy or Contract Change

❑ Member/Dependent change

❑ PCP Change

❑ Dues Payment & Billing information

❑ Claims information

❑ Medical care and treatment

❑ Vision care and treatment

❑ Dental care and treatment

❑ Other (please specify) _______________________________________________________

_______________________________________________________________________

* If this authorization is for mental health, substance abuse, or HIV information, a separate completed

authorization form will be necessary for the release of information (1) protected by the LPS Act or

(2) containing HIV results. Further, the LPS Act often requires that both the patient’s treating physician

and the patient sign the authorization form before information may be released.

4. Information may be Released to:

Name of individual or organization: ________________________________________________

Relationship: ________________________________________________________________

Name of individual or organization: ________________________________________________

Relationship: ________________________________________________________________

5. P urpose & Limitations of the Authorization: By signing this form, you authorize the use and disclosure

of the personal & health information above by a third party for the following purpose; please also list any

limitations you would like to place on the use of this information:

__________________________________________________________________________

Authorization For Release Of Personal & Health Information - Blue Shield Of California