Authorized Delegate Form (Page 2 of 2) in pdf

Section E: Important Information

No Conditions. BCBSLA will continue providing you with services if you do not complete this form.

We will just not be able to share your information with the people you list unless this form is

completed.

Further disclosure. If person(s) or company listed in Section D is not required to follow the federal

health information privacy laws, they may further share your information and it may no longer be

protected by the federal health information privacy laws.

Expiration. This authorization will automatically expire upon BCBSLA’s knowledge that you have

ended your health insurance coverage.

Right to Revoke. You may withdraw your permission to allow BCBSLA to share your information

with those listed on this form by writing to the Privacy Office. Withdrawing your permission will not

affect any action taken before we received your letter.

Section F: Member Signature (required)

_______________________________________, have read and thought about the contents of

this

form. I agree that the information I put on this form is correct. I understand that by signing this form I

am giving permission to BCBSLA to share my protected health information with those listed in

Section D.

Signature:__________________________________________ Date:________________

If this form is signed by someone other than the member, please complete Section G.

Section G: Legal Representative

If this authorization is signed by a legal representative * or someone other than the member on behalf

of the person listed in Section C, complete the following:

Personal Representative’s Name: _____________________________________________

Relationship to the Individual: _______________________________________________

NOTE: You MUST attach legal documentation of guardianship or Power of Attorney. This

documentation is required to process the authorization form.

* Legal representative is a legal designation and generally refers to the parent of a minor, legal

guardian, or holder of Power of Attorney.

Privacy Office

5525 Reitz Avenue, Baton Rouge, LA 70809-3802

Phone: (225) 298-1751

Send Completed Forms to:

Customer Service

Blue Cross and Blue Shield of Louisiana

P.O. Box 98029

Baton Rouge, LA 70898-9029

Fax: (225) 297-2727 or (225) 295-2494

Authorized Delegate Form Page 2