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Consent for Release of Protected Health Information for Medicare Supplement Members

If you have a Blue Cross Blue Shield of Michigan Medicare Supplement 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.

Fields with asterisks are required.

For assistance completing this form, call the number on the back of your member ID card.
 First name is required.
 Last name is required.
 Date of birth is required.  Invalid date format. Please use MM/DD/YYYY.
 Phone number is required.  This is not a valid phone number.
 Enrollee ID, found on your Blue Cross ID card is required.
 Street address is required.
 City is required.
 Select a state is required.
 ZIP code is required.  This is not a valid ZIP code.

You have my permission to share

Please check one
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.

Recipients full name
 Full name of person or organization is required.
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*

 The authorizaiton checkbox is required.
 Signature of member is required.
 Date is required.  Invalid date format. Please use MM/DD/YYYY.
 Recaptcha is required.

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.

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