AFFIDAVIT OF NEXT OF KIN
Use this form to manage the protected health information of someone
who’s passed away.
Enrollee ID of deceased member
The undersigned, being first duly sworn, deposes and states:
1. I am the next of kin of
who died on or about the day of , 20 .
2. A copy of the decedent’s death certificate is attached.
3.
My relationship to the decedent is .
4. No personal
representative
has been appointed for the decedent’s estate in this state or elsewhere and no application
for such
appointment
is pending in this state or elsewhere.
5. This affidavit is made in support of
my
request to facilitate claims payment. I agree and understand that, pursuant to
federal law, Blue Cross and Blue Shield of Michigan or its affiliates will not release copies of the medical records of
the decedent to me or allow me to change the address of record.
The foregoing is the truth to the best of my knowledge, information and belief.
Dated at , this day of , 20 .
City State
Signature
Print name
Address
Telephone
Sworn and subscribed before me, on
Notary p
ublic
My commission expires on
WF 16098 SEP 16 Page 1 of 3
Mailing instructions Faxing instructions
Please mail completed authorizations to:
BCBSM
Mail Code X425
600 E. Lafayette Blvd.
Detroit, MI 48226
Please fax completed authorizations to:
1-866-894-3101.
Members who need additional assistance completing this form should call a customer service representative at the
number on the back of their Blues ID card.
WF 16098 SEP 16 Page 2 of 3
Se tu o qualcuno che stai aiutando avete bisogno di assistenza, hai
il diritto di ottenere aiuto e informazioni nella tua lingua
gratuitamente. Per parlare con un interprete, rivolgiti al Servizio
Assistenza al numero indicato sul retro della tua scheda o chiama
il 877-469-2583, TTY: 711 se non sei ancora membro.
ご本人様、またはお客様の身の回りの方で支援を必要とさ
れる方でご質問がございましたら、ご希望の言語でサポー
トを受けたり、情報を入手したりすることができます。料
金はかかりません。通訳とお話される場合はお持ちのカー
ドの裏面に記載されたカスタマーサービスの電話番号
(メンバーでない方は 877-469-2583, TTY: 711)
までお電話ください。
We speak your language
If you, or someone you’re helping, needs assistance, you have the
right to get help and information in your language at no cost. To
talk to an interpreter, call the Customer Service number on the
back of your card, or 877-469-2583, TTY: 711 if you are not
already a member.
Si usted, o alguien a quien usted está ayudando, necesita
asistencia, tiene derecho a obtener ayuda e información en su
idioma sin costo alguno. Para hablar con un intérprete, llame al
número telefónico de Servicio al cliente, que aparece en la parte
trasera de su tarjeta, o 877-469-2583, TTY: 711 si usted todavía no
es un miembro.
إاذ ﺖﻨأ ﺖﻧ وأ ﺺﺨﺧآﺴﺗهﺤﺑﺟﺎﺴﻤة ،ﻠﻓا ﻲﻓاﺼﺤ لﻠﻋ
اﺴﻤ ةﻟاوﻠﻌتاﻀﻟوﯾرﺘﻐود نﯾأﻠﻜﺔﻔ. ﻠﻟ ثﺪﻟإﺘﻣاﺼﺗ
اﻤﻌﻟءاﺟﻮ دﻮ ﻰﻠﮭظ ، وأ877-469-2583 TTY:711 ،ذإ ا
ﻦﻜﺗ ﺸﻣﻟﺎ.
Если вам или лицу, которому вы помогаете, нужна помощь, то
вы имеете право на бесплатное получение помощи и
информации на вашем языке. Для разговора с переводчиком
позвоните по номеру телефона отдела обслуживания
Da biste razgovarali sa prevodiocem, pozovite broj korisničke
službe sa zadnje strane kartice ili 877-469-2583, TTY: 711 ako već
niste član.
Kung ikaw, o ang iyong tinutulungan, ay nangangailangan ng
tulong, may karapatan ka na makakuha ng tulong at impormasyon

،




 ،




،












.






، 













877-469-2583 TTY:711

.
如果您,
或是您正在協助的對象,需要協助,您有權利免費
клиентов, указанному на обратной стороне вашей карты, или
以您的母語得到幫助和訊息。要洽詢一位翻譯員,請撥在您
по номеру 877-469-2583, TTY: 711, если у вас нет членства.
的卡背面的客戶服務電話;如果還不是會員,請撥電話
Ukoliko Vama ili nekome kome Vi pomažete treba pomoć, imate
877-469-2583, TTY: 711
pravo da besplatno dobijete pomoć i informacije na svom jeziku.
sa iyong wika ng walang gastos. Upang makausap ang isang
tagasalin, tumawag sa numero ng Customer Service sa likod ng
iyong tarheta, o 877-469-2583, TTY: 711 kung ikaw ay hindi pa
isang miyembro.
Important disclosure
Blue Cross Blue Shield of Michigan and Blue Care Network comply
with Federal civil rights laws and do not discriminate on the basis
of race, color, national origin, age, disability, or sex. Blue Cross
Blue Shield of Michigan and Blue Care Network provide free
auxiliary aids and services to people with disabilities to
communicate effectively with us, such as qualified sign language
interpreters and information in other formats. If you need these
services, call the Customer Service number on the back of your
card, or 877-469-2583, TTY: 711 if you are not already a member.
If you believe that Blue Cross Blue Shield of Michigan or Blue Care
Network has failed to provide services or discriminated in another
way on the basis of race, color, national origin, age, disability, or
sex, you can file a grievance in person, by mail, fax, or email with:
Office of Civil Rights Coordinator, 600 E. Lafayette Blvd., MC 1302,
Detroit, MI 48226, phone: 888-605-6461, TTY: 711,
fax: 866-559-0578, email:
CivilRights@bcbsm.com. If you need
help filing a grievance, the Office of Civil Rights Coordinator is
available to help you.
You can also file a civil rights complaint with the U.S. Department
of Health & Human Services Office for Civil Rights electronically
through the Office for Civil Rights Complaint Portal available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail, phone,
or email at: U.S. Department of Health & Human Services,
200 Independence Ave, S.W., Washington, D.C. 20201,
phone: 800-368-1019, TTD: 800-537-7697,
email: OCRComplaint@hhs.gov. Complaint forms are
available at http://www.hhs.gov/ocr/office/file/index.html.
Page 3 of 3
Nếu quý v, hay ngưi mà quý vđang giúp đ, cn trgiúp, quý v
scó quyn đưc giúp và có thêm thông tin bng ngôn ngca
mình min phí. Đnói chuyn vi mt thông dch viên, xin gi s
Dch vKhách hàng mt sau thca quý v, hoc 877-469-2583,
TTY: 711 nếu quý vchưa phi là mt thành viên.
Nëse ju, ose dikush që po ndihmoni, ka nevojë për asistencë, keni
të drejtë të merrni ndihmë dhe informacion falas në gjuhën tuaj.
Për të folur me një përkthyes, telefononi numrin e Shërbimit të
Klientit në anën e pasme të kartës tuaj, ose 877-469-2583,
TTY: 711 nëse nuk jeni ende një anëtar.
만약 귀하 또는 귀하가 돕고 있는 사람이 지원이 필요하다면 ,
귀하는 도움과 정보 귀하의 언어로 비용 부담 없이 얻을
있는 권리가 있습니 . 통역사와 대화하려면 귀하의 카드
뒷면에 있는 고객 서비스 번호로 전화하거나 , 이미 회원이
아닌 경우 877-469-2583, TTY: 711 전화하십시오 .
 ,      ,   ,
        
      ,   
       877-469-2583, TTY: 711
      
Jeśli Ty lub osoba, której pomagasz, potrzebujecie pomocy, masz
prawo do uzyskania bezpłatnej informacji i pomocy we własnym
języku. Aby porozmawiać z tłumaczem, zadzwoń pod numer
działu obsługi klienta, wskazanym na odwrocie Twojej karty lub
pod numer 877-469-2583, TTY: 711, jeżeli jeszcze nie masz
członkostwa.
Falls Sie oder jemand, dem Sie helfen, Unterstützung benötigt,
haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer
Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen,
rufen Sie bitte die Nummer des Kundendienstes auf der Rückseite
Ihrer Karte an oder 877-469-2583, TTY: 711, wenn Sie noch kein
Mitglied sind.
WF 16098 SEP 16