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Section C: Authorized Use and/or Disclosure
Relationship to Member in Section B
Section D: Type of Information
I allow the following information to be used or disclosed by BCBSND on my behalf.
Select either “All My Information” or “Only Limited Information.” Do not choose both.
All My Information* Includes premium, billing, payment, health, diagnosis, claims, doctor and other provider
information, including sexually transmitted disease, AIDS, HIV, behavioral, mental health and other sensitive medical
information that applicable law may protect.
OR
Only Limited Information* By checking this box you indicate you want only specific information to be disclosed.
Check the appropriate box. If there is not an appropriate box, check the Other box and describe the specific
information to be disclosed in the space provided. (check all that apply)
Appeal Information
Eligibility and Enrollment
Benefits and Coverage
Pre-certification and Pre-authorization
Premium Billing and Payment
Referral
Claims and Payment
Pharmacy
Other _________________________________________________________________________________
*Does not include records protected by 42 C.F.R. Part 2. Requests for use and disclosure of these records should
use the Authorization to Release Information Form.
Section E: Expiration and Revocation
For North Dakota residents, this authorization will remain in eect for 18 months past your plan’s termination date.
For residents of all other states, this authorization will terminate 12 months from the date of signature below.
If you are under 18 years of age, this authorization will terminate as of your 18th birthday.
By checking this box, I am indicating that I wish this authorization to terminate in the event of my death.
If this box is not checked, this authorization will remain valid as indicated above.
I understand that I have the right to revoke or end this authorization at any time. I understand that if I do not wish the
person(s) named in Section C to remain my Authorized Representative(s), I must revoke this authorization in writing
by giving written notice of my decision to the benefit plan at the address listed on the back of my member ID card.
I understand that my revocation of this authorization will not aect any action that you have already taken or any
information that you have already released, based upon this authorization before you receive my request to revoke
it. I also understand that my revocation may not be eective in preventing release of certain health information to a
personal representative, such as a parent, guardian, or person acting in the capacity of a parent or guardian, whom
applicable law allows to have access to such health information without my written permission.
Section F: Signature/Authorization
I understand this authorization is voluntary. I understand my treatment, payment, enrollment or eligibility for benefits is
not conditioned on receiving this authorization.
I have had full opportunity to read and consider the contents of this authorization. I understand that, by signing this
form, I am confirming my authorization for the use and/or disclosure of my protected health information, as described
in this form.
Print Name
Signature Date (mm/dd/yyyy)
Page 2 of 2
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signature
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