Consent for release of Protected Health Information (PHI) for Medicare HMO members

This completed form will need to be submitted before BCN Advantage can share your PHI with an individual or organization.

IMPORTANT:

Not completing all required information will mean you'll have to start over with a new form.
This form is for one member only. Additional members will need to submit their own forms.
For help completing this form, call the number on the back of your member ID card.

Personal information

* First name

* Last name

* Date of birth

* Phone

* Subscriber ID number, also known as enrollee ID, on member ID card including one- to three-letter prefix

* Street address

* City

* ZIP code

You have my permission to share:

Check one:

Any personal information Only limited information

If "Only limited information" please tell us what not to share

Indicate which highly protected information, known as Super PHI, you'll allow us to share:

Substance use records, including alcoholism

AIDS or HIV treatment records

Mental health services not including psychotherapy notes

Person or organization that 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.

Supply person’s first and last name and/or the organization's name, such as a hospital name and department.

* Full name of person and/or organization receiving your PHI

* Check the box describing the person/organization’s relationship to you. Family member Friend Doctor or health care provider Other; please describe

Cancellation of your permission to share PHI

* This permission is cancelled: On this date: month, day and year, MM/DD/YYYY)

Upon my death

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

I allow the use and disclosure of my protected health information as described above. This information is being released at my request. I understand that my treatment, payment, enrollment or eligibility for benefits does not depend on whether I sign this authorization. By clicking this box, I acknowledge that I am the BCBSM Member listed in the form herein. Further, I have read, understand, and agree that all the information provided in this form is true. By clicking this box, I agree that the electronic signature that appears on this form shall have the same force and effect as handwritten signatures for the purpose of validity, enforceability and admissibility.

* Signature of member

* Date

Type the above number:

* “Blue Cross,” “we” or “us” refers to Blue Cross Blue Shield of Michigan, Blue Care Network, Blue Care Network Service Company, Blue Care of Michigan, Inc. or Blue Cross Complete of Michigan.