Member Requested Authorization For Release Of Information printable pdf download

Member Requested Authorization For Release Of Information

Member Requested

Authorization for

Release of Information

Please read these instructions carefully before completing this form.

When to Use This

Complete this form if you want Blue Cross to give information about you to someone

Form

else (e.g., an agent or family member). You must also use this form if you want

someone to act on your behalf to question a claim or appeal a benefit decision.

Parents or a legal guardian may sign for a minor unless the minor is permitted under

state law to consent to the treatment. In that case, the minor must sign the

authorization.

How to Complete This

The Authorization for Release of Information form must be completed and signed by

Form

one of the following:

♦ The person whose information will be released

♦ The parent or legal guardian of a minor whose information will be released

except as noted above

♦ The personal representative of the person whose information will be released

(e.g., power of attorney, conservator, executor)

To complete this form:

♦ Fill in the name, member identification and date of birth of the person whose

information will be released

♦ Check the type(s) of information you want us to release

♦ Decide if you want us to send your claim notices and any member payment for

the claims to the person

♦ Fill in the name and address of the person or group who will receive the

information

♦ State the purpose for this authorization unless it is at the request of the member

or the member’s personal representative

♦ Sign and date the form

♦ If you are not the person whose record will be released, state your relationship to

that person

Mail or fax this form to

Blue Cross and Blue Shield of Minnesota and Blue Plus

P.O. Box 64560

St. Paul MN 55164-0560

Fax: 651-662-7933

Note: Federal law says that Psychotherapy notes cannot be released using the same authorization form as

other records. In order to release Psychotherapy notes, you need to fill out a separate authorization form.

F7416R07 (8/08)

Member Requested Authorization For Release Of Information