Fillable AUTHORIZATION TO RELEASE INFORMATION FORM (Blue Cross Blue Shield of North Dakota)

Fill Online, Printable, Fillable, Blank AUTHORIZATION TO RELEASE INFORMATION FORM (Blue Cross Blue Shield of North Dakota) Form

Use Fill to complete blank online BLUE CROSS BLUE SHIELD OF NORTH DAKOTA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

AUTHORIZATION TO RELEASE INFORMATION FORM (Blue Cross Blue Shield of North Dakota)

On average this form takes 10 minutes to complete

The AUTHORIZATION TO RELEASE INFORMATION FORM (Blue Cross Blue Shield of North Dakota) form is 3 pages long and contains:

  • 1 signature
  • 11 check-boxes
  • 31 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Blue Cross Blue Shield of North Dakota forms online.

BROWSE BLUE CROSS BLUE SHIELD OF NORTH DAKOTA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
BND-21-0016629A • 1-22
Page 1 of 3
4510 13th Avenue South, Fargo, North Dakota 58121
AUTHORIZATION TO RELEASE
INFORMATION FORM
Authorization to Disclose Health Information (ADHI) (Medical Coverage)
You are entitled to a copy of this form after you sign it. Please notify us of any changes to the information
provided on this form. If you have questions, please call the number on the back of your member ID card.
Return completed forms by:
• Portal: Complete and save this form to your desktop to submit through the Member Portal.
To upload, attach it as part of a request through the Message Center’s Contact Us feature.
When lling out the form please select “General - Other” as your topic.
• Fax: (701) 282-1888
• Mail: BCBSND
4510 13th Ave S
Fargo, ND 58121
Section A: Purpose of Form
This form is used to request and authorize Blue Cross Blue Shield of North Dakota to use and disclose
my health information with another person or entity.
Section B: Member Information
Please type or print clearly. This individual should sign Section F.
Member ID Daytime Phone Number
Last Name First Name MI Sux Birth Date (mm/dd/yyyy)
Address
Apartment/Unit/Lot/Suite
City State Zip Code
PLEASE COMPLETE ALL PAGES OF THIS FORM.
If you have questions, please call the number on the back of your member ID card.
Blue Cross Blue Shield of North Dakota is an independent
licensee of the Blue Cross & Blue Shield Association
BND-21-0016629A • 1-22
Page 2 of 3
Section C: Authorized Use and/or Disclosure
By signing this form, I am allowing Blue Cross Blue Shield of North Dakota to use and disclose my health
information as outlined in Section D with the following individual(s) and/or organization(s) listed below.
I understand that if the individual(s) and/or organization(s) is not subject to federal or applicable
state privacy laws, my health information may no longer be protected by those privacy laws, and the
individual(s) and/or organization(s) may further use and disclose my health information without my
authorization. I acknowledge that my authorization is voluntary.
Individual or Entity Name Phone Number
Address
Apartment/Unit/Lot/Suite
City State Zip Code
Section D: Type of Information
I allow the following information to be used or disclosed by BCBSND on my behalf
(CHECK ONLY ONE BOX):
Psychotherapy Notes: Federal law requires a separate authorization to use or release
psychotherapy notes. If you check this box, you may not check another box below.
OR
All My Information: Includes health diagnosis, claims, doctors, premium billing and payment
information, including maternity, sexually transmitted disease, AIDS, HIV, alcohol, drug or other
substance abuse, behavioral and mental health and other sensitive medical information that
applicable law may protect.
OR
Only Limited Information (Check all that apply):
Appeal information
Benets and coverage
Premium billing and payment
Claims and payment
Other: __________________________________
Eligibility and enrollment
Pre-certication and pre-authorization
Referral
Pharmacy
Note: Certain Federal and State laws require that you give specic permission to use or
release the information below, even if you checked a box above. Indicate your permission
for the disclosure of the following information by checking all that apply:
Alcohol/substance abuse*
Other: ___________________________________
* I understand that my alcohol/substance abuse records are protected under Federal and State
condentiality laws and regulation and cannot be used or disclosed without my written consent
unless otherwise provided for in the laws and regulations.
BND-21-0016629A • 1-22
Page 3 of 3
Section E: Expiration and Revocation
This authorization will be valid for this one-time release of information unless otherwise specied
below. Any date specied cannot exceed 12 months from the date of the covered member’s
signature below.
Valid for one year from the signature date in Section F.
Earlier than one year and upon the date or event described below:
________________________________________________________________________________________________________
I may revoke this authorization at any time by giving written notice of revocation to BCBSND Member
Services at the address listed on the back of my member ID card. I understand that my revocation
of this authorization will not aect any action that you have taken, or any information that you have
already released, based upon this authorization before you actually receive my request to revoke it.
Section F: Signature/Authorization
I understand this authorization is voluntary. I understand my treatment, payment, and enrollment in a
health plan or eligibility for benets 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 conrming my authorization for the use and/or disclosure of my protected
health information, as described in this form.
Printed First Name Printed Last Name
Signature Today’s Date (mm/dd/yyyy)
click to sign
signature
click to edit
4510 13
th
Avenue South, Fargo, North Dakota 58121
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross Blue Shield Association
BND-21-003795 • 1-19
In accordance with federal regulations, Blue Cross Blue Shield of North Dakota is required to provide you the
following disclosure:
Blue Cross Blue Shield of North Dakota complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, gender identity, sexual orientation
or sex. Blue Cross Blue Shield of North Dakota does not exclude people or treat them differently because of
race, color, national origin, age, disability, gender identity, sexual orientation or sex.
Blue Cross Blue Shield of North Dakota:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you need these services, please call Member Services at 1-844-363-8457 (toll-free) or through the
North Dakota Relay at 1-800-366-6888 or 711.
If you believe that Blue Cross Blue Shield of North Dakota has failed to provide these services or discriminated
in another way on the basis of race, color, national origin, age, disability, gender identity, sexual orientation
or sex, you can file a grievance with:
Civil Rights Coordinator
4510 13th Ave S
Fargo, ND 58121
701-297-1638 or North Dakota Relay at 800-366-6888 or 711
701-282-1804 (fax)
CivilRightsCoordinator@bcbsnd.com (email) (Communication by unencrypted email presents a risk.)
You can file a grievance in person or by mail, fax, or email within 180 days of the date of the alleged
discrimination. Grievance forms are available at http://www.bcbsnd.com/report or by calling 1-844-363-8457.
If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and 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 or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue SW.
Room 509F, HHH Building
Washington, DC 20201
800-368-1019 or 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
Español (Spanish)
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-844-363-8457 (TTY: 1-800-366-6888 o 711).
Deutsch (German)
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur
Verfügung. Rufnummer: 1-844-363-8457 (TTY: 1-800-366-6888 oder 711).
中文 (Chinese)
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-844-363-8457（TTY：1-800-366-6888 或
711）。
Oroomiffa (Oromo)
XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa
1-844-363-8457 (TTY: 1-800-366-6888 ykn 711).
Tiếng Việt (Vietnamese)
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn.
Gọi số 1-844-363-8457 (TTY: 1-800-366-6888 hoặc 711).
Ikirundi (Bantu – Kirundi)
ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu.
Woterefona 1-844-363-8457 (TTY: 1-800-366-6888 canke 711).
اﻟﻌرﺑﯾﺔ (Arabic)
ﻣﻠﺣوظﺔ: إذا ﻛﻧت ﺗﺗﺣدث اذﻛر ا ﻟ ﻠﻐﺔ، ﻓﺈن ﺧدﻣﺎت ا ﻟﻣ ﺳﺎﻋدة ا ﻟ ﻠﻐوﯾﺔ ﺗﺗواﻓر ﻟك ﺑ ﺎ ﻟﻣ ﺟﺎن. ا ﺗﺻل ﺑرﻗم
844-363-8457-1 )رﻗ م ھ ﺎ ﺗف ا ﻟﺻم و ا ﻟ ﺑ ﻛم :
1-800-366-6888 أو 711(.
Kiswahili (Swahili)
KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo.
Piga simu 1-844-363-8457 (TTY: 1-800-366-6888 au 711).
Русский (Russian)
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.
Звоните 1-844-363-8457 (телетайп: 1-800-366-6888 или 711).
日本語
(Japanese)
注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-844-363-8457
（TTY: 1-800-366-6888 または 711）まで、お電話にてご連絡ください。
नेपाल& (Nepali)
!यान %दन
ु
होस
्
: तपाइ/ले नेपाल2 बो4न
ु
ह
ु
5छ भने तपाइ/को 9नि;त भाषा सहायता सेवाह> 9नःश
ु
4क >पमा उपलCध छ । फोन गन
ु
Hहोस
्
1-844-363-8457 (%ट%टवाइ: 1-800-366-6888 वा 711) ।
Français (French)
ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement.
Appelez le 1-844-363-8457 (ATS : 1-800-366-6888 ou 711).
한국어 (Korean)
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-844-363-8457
(TTY: 1-800-366-6888 또는 711)번으로 전화해 주십시오.
Tagalog (Tagalog – Filipino)
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad. Tumawag sa 1-844-363-8457 (TTY: 1-800-366-6888 o 711).
Norsk (Norwegian)
MERK: Hvis du snakker norsk, er gratis språkassistansetjenester tilgjengelige for deg. Ring 1-844-363-8457
(TTY: 1-800-366-6888 eller 711).
Diné Bizaad (Navajo)
Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dę
́
ę
́
’, t’áá jiik’eh, éí ná hólǫ
́
,
kojį’ hódíílnih 1-844-363-8457 (TTY: 1-800-366-6888 éí doodagó 711.)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

AUTHORIZATION TO RELEASE INFORMATION FORM (Blue Cross Blue Shield of North Dakota)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 12 May 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document