Anthem BlueCross Member Authorization Instructions and Form

Instructions for Completing the Member Authorization Form
If you have any questions, please feel free to call us at the customer service number on your member identification card.
Please read the following for help completing page one of the form.
Part A: Member Information
This section applies to the member who is asking for
the release of his or her information to another person
or company.
1
Print your last name, first name, and middle initial
2
Write your date of birth in this format: mm/dd/yyyy.
(If you were born on October 5, 1960, you would
write 10/05/1960.)
3
Write your full street address, city, state, and ZIP code
4
Write your daytime phone number (including area code)
5
Identification number
You will find this number on your member
identification card
6
Group number
You will find this number on your member identification
card. If your identification card does not have a group
number leave this blank.
Part B: Person or company who will receive
this information
7
Check the box that applies to you. Write the full name
of the person or company that you want us to give your
information to. Please don't use a general term like
“my daughter” or “my son” as it will not be accepted.
You need to be specific.
8
If you check “Other,” give the first and last name
(if available), the name of the company (if applicable),
and how they relate to you.
Member Authorization Form
Si necesita ayuda en español para entender este documento, puede solicitarla sin costo adicional, llamando al número de servicio
al cliente que aparece al dorso de su tarjeta de identificación o en el folleto de inscripción.
This form is to be filled out by a member if there is a request to release the member’s health information to another person or company.
Please include as much information as you can.
Part a: MeMber inforMation
Member last name
Member first name
Middle
Member date of birth
initial
1
2
Member street address
City
3
Daytime telephone number (with area code)
State
Identification number (see identification card) Group number (see identification card)
4
5
6
Part b: Person or coMPany who will receive this inforMation
The following people or companies have the right to receive my information. (They must be 18 years of age or older). Please check
each box that applies and enter first and last name.
My spouse (enter first and last name)
My parents (if you are over 18 – enter first and last name[s])
7
My domestic partner (enter first and last name)
My insurance broker or agent (enter the name of the company
and first and last name, if you have it)
My adult children (enter first and last name[s])
Other (enter first and last name [if you have it], name of company,
and how it’s related to you)
8
Part c: inforMation that can be released
I allow the following information to be used or released by Anthem Blue Cross on my behalf (check only one box):
9
all my information. This can include health, a diagnosis (name of illness or condition), claims, doctors and other health care
providers and financial information (like billing and banking). This doesn’t include sensitive information (see below) unless it is
approved below.
or
only limited information may be released (check all boxes below that apply to you).
10
Appeal
Eligibility and enrollment
Referral
Benefits and coverage
Financial
Treatment
Billing
Medical records
Dental
Claims and payment
Vision
Doctor and hospital
Diagnosis (name of illness
Pharmacy
Pre-certification and pre-authorization
or condition) and procedure
(for treatment approvals)
Other: _______________
(treatment)
I also approve the release of the following types of sensitive information by Anthem Blue Cross (check all boxes that apply to you):
11
all sensitive information
or
Just information about topics checked below
Abortion
Genetic testing
Mental health
Abuse (sexual/physical/mental)
HIV or AIDS
Sexually transmitted illness
Alcohol/substance abuse **
Maternity
Other: _______________
** I understand that my alcohol/substance abuse records are protected under Federal and State confidentiality laws and regulations and cannot
be disclosed without my written consent unless otherwise provided for in the laws and regulations. I also understand that I may revoke
(or cancel) this approval at any time, or as described below in Part E. I understand that I cannot cancel this approval when this form has
already been used to disclose information.
22940CAMENABC 3/12
Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association.
® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.
274730 22940CAMENABC HIPAA Member Authorization Prt FR 03 12
Part C: Information that can be released
This section tells us what information you would like us
to release: all or just some.
9
For “all of your information,” check the first box.
10
For “limited information,” check the second box
and the boxes that apply to you.
11
Some topics may be very personal or sensitive to you.
If you wish to approve the release of this type of
information, check the box(es) that apply to you.
22940CAMENABC 3/12
ZIP code
Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association.
® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.
1 of 2
Please read the following for help completing page two of the form.
Part D: Purpose of this approval
This section tells us the reason you’ve asked for the
release of your information.
1
Check the first box to let us know to give out this
information as shown on this form.
2
Check the second box for a specific reason.
An example might be to settle a life insurance claim.
Part E: Date your approval expires
You have two choices of when you would like this
approval to end.
3
Check the first box for the standard one-year
that it will end.
4
Check the second box for an earlier date (other than
one year), and give the date you wish this approval
to end.
Your authorization/approval can’t be granted for more
than one year.
PArT d: PurPOse OF ThIs APPrOvAl
To give out the information as shown on this form
Or
For this reason(s): _________________________________________________________________________
2
PArT e: dATe yOur APPrOvAl exPIres
If this document was not already withdrawn, this approval will end on the earliest of the following dates:
3
One year from the signature date in Part F
Or
4
Earlier than one year and upon the date, event or condition described below
______________________________________________________________________________________
PArT F: revIeW And APPrOvAl
I have read the contents of this form. I understand, agree, and allow Anthem Blue Cross to the use and release of my information as
I have stated above. I also understand that signing this form is of my own free will. I understand that Anthem Blue Cross does not
require that I sign this form in order for me to receive treatment or payment, or for enrollment or being eligible for benefits.
I have the right to withdraw this approval at any time by giving written notice of my withdrawal to Anthem Blue Cross. I understand
that my withdrawing this approval will not affect any action taken before I do so. I also understand that information that’s released
may be given out by the person or group who receives it. If this happens, it may no longer be protected under the HIPAA Privacy Rule.
I am entitled to a copy of this form.
1
Member signature or Designated Legal Representative/Guardian signature
X
Date
5
6
desIGnATed leGAl rePresenTATIve/GuArdIAn
If this form is signed by someone other than the member or parent, such as a personal representative, legal representative or
guardian on behalf of the member, please submit the following:
}} A copy of a health care, general or Durable Power of Attorney.
Or
}} A court order or other documentation that shows custody or other legal documentation showing the authority of the legal
representative to act on the member’s behalf.
Please complete the following:
Legal representative (print full name)
Legal relationship to member
Legal representative street address
City
State ZIP code
Date
Signature
X
Part F: Review and approval
5
Sign your name and put the date on the form.
Your name and signature must match the
information in Part A.
6
If you are signing this form on behalf of another
person, or if you have Power of Attorney for
health care, or are a legal guardian/conservator
you must do the following:
}}You must complete the Designated Legal
Representative/Guardian section.
}}You must also provide us with a copy of the legal
document showing that you are approved and
include it with this form.
Please return the completed form to:
Anthem Blue Cross
<Street address>
<City, state, ZIP code>
be sure to keep a copy of this form for your records.
FOr recIPIenT OF subsTAnce Abuse InFOrMATIOn
This information has been disclosed to you from records protected by Federal Confidentiality of Alcohol or Drug Abuse Patient
Records rules (42 CFP part 2). The Federal rules prohibit you from making any further disclosure of this information unless further
disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR
part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules
restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
For internal use only:
Inquiry tracking number
Examples of legal documents:
}}Health Care, General or Durable Power of Attorney. This document gives someone you trust the legal power to act on your
behalf and make health care decisions for you.
}}Legal Guardianship. This is when the court appoints someone to care for another person.
}}Conservatorship. This happens when a judge appoints a responsible person to make decisions for someone who can’t make
responsible decisions for him/herself.
}}Executor of estate. This type of document would be used when the person who is being represented has died.
2 of 2
Member Authorization Form
Si necesita ayuda en español para entender este documento, puede solicitarla sin costo adicional, llamando al número de servicio
al cliente que aparece al dorso de su tarjeta de identificación o en el folleto de inscripción.
This form is to be filled out by a member if there is a request to release the member’s health information to another person or company.
Please include as much information as you can.
Part A: Member information
Member last name
Member first name
Middle
Member date of birth
initial
Member street address
City
Daytime telephone number (with area code)
State
ZIP code
Identification number (see identification card) Group number (see identification card)
Part B: Person or company who will receive this information
The following people or companies have the right to receive my information. (They must be 18 years of age or older). Please check
each box that applies and enter first and last name.
My spouse (enter first and last name)
My parents (if you are over 18 – enter first and last name[s])
My domestic partner (enter first and last name)
y insurance broker or agent (enter the name of the company
M
and first and last name, if you have it)
My adult children (enter first and last name[s])
Other (enter first and last name [if you have it], name of company,
and how it’s related to you)
Part C: Information that can be released
I allow the following information to be used or released by Anthem Blue Cross on my behalf (check only one box):
All my information. This can include health, a diagnosis (name of illness or condition), claims, doctors and other health care
providers and financial information (like billing and banking). This doesn’t include sensitive information (see below) unless it is
approved below.
OR
Only limited information may be released (check all boxes below that apply to you).
Appeal
Eligibility and enrollment
Referral
Benefits and coverage
Financial
Treatment
Billing
Medical records
Dental
Claims and payment
Vision
Doctor and hospital
Diagnosis (name of illness
Pharmacy
Pre-certification and pre-authorization
or condition) and procedure
(for treatment approvals)
Other: _______________
(treatment)
I also approve the release of the following types of sensitive information by Anthem Blue Cross (check all boxes that apply to you):
All sensitive information
OR
Just information about topics checked below
Abortion
Genetic testing
Mental health
Abuse (sexual/physical/mental)
HIV or AIDS
Sexually transmitted illness
Alcohol/substance abuse **
Maternity
Other: _______________
** I understand that my alcohol/substance abuse records are protected under Federal and State confidentiality laws and regulations and cannot
be disclosed without my written consent unless otherwise provided for in the laws and regulations. I also understand that I may revoke
(or cancel) this approval at any time, or as described below in Part E. I understand that I cannot cancel this approval when this form has
already been used to disclose information.
22940CAMENABC 3/12
Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association.
® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.
274730 22940CAMENABC HIPAA Member Authorization Prt FR 03 12
1 of 2
Part d: Purpose of this approval
To give out the information as shown on this form
OR
For this reason(s): __________________________________________________________________________
Part e: Date your approval expires
If this document was not already withdrawn, this approval will end on the earliest of the following dates:
One year from the signature date in Part F
OR
Earlier than one year and upon the date, event or condition described below
_______________________________________________________________________________________
Part F: Review and approval
I have read the contents of this form. I understand, agree, and allow Anthem Blue Cross to the use and release of my information as
I have stated above. I also understand that signing this form is of my own free will. I understand that Anthem Blue Cross does not
require that I sign this form in order for me to receive treatment or payment, or for enrollment or being eligible for benefits.
I have the right to withdraw this approval at any time by giving written notice of my withdrawal to Anthem Blue Cross. I understand
that my withdrawing this approval will not affect any action taken before I do so. I also understand that information that’s released
may be given out by the person or group who receives it. If this happens, it may no longer be protected under the HIPAA Privacy Rule.
I am entitled to a copy of this form.
Member signature or Designated Legal Representative/Guardian signature
Date
X
Designated Legal Representative/Guardian
If this form is signed by someone other than the member or parent, such as a personal representative, legal representative or
guardian on behalf of the member, please submit the following:
}} A copy of a health care, general or Durable Power of Attorney.
OR
}} A court order or other documentation that shows custody or other legal documentation showing the authority of the legal
representative to act on the member’s behalf.
Please complete the following:
Legal representative (print full name)
Legal relationship to member
Legal representative street address
City
State ZIP code
Date
Signature
X
Please return the completed form to:
Anthem Blue Cross
<Street address>
<City, state, ZIP code>
Be sure to keep a copy of this form for your records.
FOR RECIPIENT OF SUBSTANCE ABUSE INFORMATION
This information has been disclosed to you from records protected by Federal Confidentiality of Alcohol or Drug Abuse Patient
Records rules (42 CFP part 2). The Federal rules prohibit you from making any further disclosure of this information unless further
disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR
part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules
restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
For internal use only:
Inquiry tracking number
2 of 2