Consent for Release of Protected Health Information for Medicare Plus Blue PPO and Prescription Blue PDP Members

If you have a Blue Cross Blue Shield of Michigan Medicare Plus BlueSM PPO or Prescription BlueSM PDP plan, you must send us this completed form before we can share your protected health information, also known as PHI, with an individual or organization. 

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For assistance completing this form, call the number on the back of your member ID card.
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You have my permission to share

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Indicate which sensitive health information you want disclosed pursuant to this authorization by checking the relevant box(es) below:

Person or organization you want to receive your PHI

Note: If you list a person or organization not legally required to obey privacy laws, then the information you share with them is not legally protected.

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What's their relationship to you?

Cancellation of your permission to share PHI

This permission is canceled.

I understand that I can cancel this permission at any time. I can cancel by submitting a written request on a standard form available online at bcbsm.com or by calling the number on the back of my member ID card. I understand that cancellation will not apply to information that has already been shared.

Authorization and signature*

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  • Page Last Updated Thu Apr 18 13:47:58 EDT 2024