Authorized Delegate Form printable pdf download

A subsidiary of Blue Cross and Blue Shield of Louisiana,

independent licensees of the Blue Cross and Blue Shield Association.

An independent licensee of the Blue Cross and Blue Shield Association.

AUTHORIZED DELEGATE FORM

Instructions:

This form is used for you to give Blue Cross and Blue Shield of Louisiana (BCBSLA)** permission to

share your protected health information with another person or company (for example, with your spouse or insurance

agent). Please fill out Section C with your information and Section D, with the information on the person or company who

is to get the information. You must also sign the form in Section F.

**BCBSLA refers to Louisiana Health Service & Indemnity Company d/b/a Blue Cross and Blue Shield of Louisiana and

its subsidiary HMO Louisiana, Inc. (collectively referred to herein as “BCBSLA”)

Section A. Purpose

This form is submitted at the request of the person listed in Section C to allow BCBSLA to share that

person’s protected health information with those listed in Section D.

Section B: Protected Health Information to be disclosed

I give BCBSLA permission to disclose any of my personal information protected by federal or state

law to the person(s) or company listed in Section D. I understand that this personal information may

contain detailed medical information, except for psychotherapy notes, HIV information, or genetic

information. (An additional authorization form is required to release those types of information).

Section C: Member Information (required)

(List the specific person whose information is to be shared, even if that person is not the policy holder.)

*Name:

*Address:

*City:

State:

Zip:

*Member ID Number:

OR Social Security Number:

Section D: Person(s) or Organization(s) to Receive Information (required)

Name the person or company to whom BCBSLA may give your protected information. We must

confirm the identity of the person(s) when they call, so please provide the date of birth or driver’s

license number of the person or the tax ID number of the company you list below.

Person / Organization #1

Person / Organization #2

*Name______________________________

*Name________________________________

*Address____________________________

*Address______________________________

*City______________State____Zip_______

*City________________State____Zip_______

*Date of Birth / Tax ID:__________________

*Date of Birth / Tax ID:___________________

*Driver’s License #: _____________________

*Driver’s License #: ______________________

*This information is required to process the form.

(Over)

23XX7434 R05/14

Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company

Authorized Delegate Form

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