Authorization for Disclosure of Health Information

X21006R06 (06/19)

Please read these instructions carefully before completing this form.

When to Use This

Form

Complete this form if you are requesting Blue Cross to release

information about you to another person or entity.

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 Form

Section 1:

¨ Fill in the name, address, member identification and date of birth of

the person whose information will be disclosed.

¨ Provide the date range of records to be disclosed. The “From” and

“To” areas must be entered as dates (mmddyyyy).

An actual date must be entered in the “From” and “To” fields.

For example: From “07/01/2018 To 12/31/2018”.

Section 2 and 3:

¨ Check the boxes to identify the type(s) of information you want us to

disclose.

Section 4:

¨ Fill in the name and address of the Individual, Organization, or

Provider.

¨ You must enter the purpose for which you want the information

disclosed.

Section 5:

This form must be completed and signed by 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).

Note: This authorization will expire one year from the date signed, unless

an earlier date is entered in this section.

Return this

completed form to

Blue Cross and Blue Shield of Minnesota

P.O. Box 64560

St. Paul MN 55164

Fax: 651-662-7933

Authorization for Disclosure of

Health Information

Authorization for Disclosure of Health Information

This form is used to authorize Blue Cross to release your protected health information to another person or entity.

Section 1 The individual whose information may be disclosed:

Patient/Member First Name Patient/Member Last Name Pt/Mbr Date of Birth (mm/dd/yyyy)

/ /

Patient/Member Address 1

Patient/Member Address 2

Patient/Member City Pt/Mbr State Pt/Mbr Zip Code

Patient/Member Identiﬁcation Number Telephone

The information authorized to be disclosed is from the following period(s):

From (mm/dd/yyyy) To (mm/dd/yyyy)

Section 2 l Check if this authorization is for chemical dependency program information.

l Check if this authorization is for psychotherapy notes.

Section 3 Information to be disclosed (Please check only that which applies):

Designated Record Set: (Please check only that which applies)

l Enrollment Information l Claims Information l Appeal Information

l Care/Case Management l All health information (including any l Billing Information

Information medical records that we may have)

l Only health information related to the following condition(s): _______________________________

_____________________________________________________________________________________

l Other _____________________________________________________________________________

Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonproﬁt independent licensees of the Blue Cross and Blue Shield Association

X21006R06 (06/19) Page 1

X21006R06 (06/19) Page 2

Section 4 This information is to be disclosed to:

l Individual, Organization or Provider is my Authorized Representative

Individual, Organization or Provider

(include address if information is to be mailed)

Information may be disclosed for the purpose of:

Section 5 I understand that I may revoke this authorization at any time by giving written notice of my revocation

to Blue Cross and Blue Shield of Minnesota and Blue Plus. I understand that revocation of this authorization will not

aﬀect any action Releaser took in reliance on this authorization before it received my written notice of revocation. I

also understand that without my written authorization, Releaser may not use or disclose my health information for

any reason except those described in Releaser’s Notice of Privacy Policies and Practices. This authorization will end

one year from the date this form is signed unless I indicate an earlier date or event here:

Expiration date (mm/dd/yyyy) or speciﬁc event

I understand that authorizing the disclosure of this health information is voluntary, and that I can refuse to sign this

authorization.

I understand that, if the persons or organizations I authorize to receive and/or use the protected health information

described above are not health plans, covered health care providers or health care clearinghouses subject to federal

health information privacy laws, they may further disclose the protected health information and it may no longer be

protected by federal health information privacy laws.

Releaser, its subsidiaries, aﬃliates, employees, oﬃcers, and physicians are hereby released from any legal

responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

Sign only one of the signatures below:

Signed: (Patient/Member)

Signed: (Personal Representative)

Date (mm/dd/yyyy) Date (mm/dd/yyyy)

(Include a description/documentation of such representative’s authority to act for the patient)

Please mail the completed form to: Blue Cross and Blue Shield of Minnesota

P.O. Box 64560

St. Paul, MN 55164

This form can also be faxed to (651) 662-7933