AUTHORIZATION TO RELEASE “PROTECTED HEALTH INFORMATION” – ACCESS
PURPOSE
This authorization is at my request to permit Blue Cross and Blue Shield of Florida, Inc., Health
Options, Inc. and Florida Combined Life Insurance Company, Inc. (together, BCBSF) to respond
to customer service inquiries regarding my Protected Health Information.
SECTION I
Please provide the following information regarding the person whose Protected Health
Information is to be released.
Member Name: ______________________________________________________
Policy or Contract Number: _____________________________________________
Group Number: ______________________Date of Birth: _____________________
SECTION II
I authorize BCBSF to release the following Protected Health Information concerning the
member listed in Section I:
• Identifying information (e.g., name, address, age, gender);
• Health care coverage information; and
• Past, present and future claims information (except for any period of time during which a
PHI address
1
was in effect).
SECTION III
Please identify the person(s) with whom the member’s Protected Health Information may be
released to and their relationship.
Please Print
Name: _________________________ Relationship to Member: _______________
Name: _________________________ Relationship to Member: _______________
Name: _________________________ Relationship to Member: _______________
SECTION IV
By law, this authorization must indicate that persons other than BCBSF receiving member’s
Protected Health Information may not have to obey federal health information privacy laws and
member’s Protected Health Information may be further released by those persons.
This authorization is voluntary and is not a condition of enrollment in a health plan, eligibility for
benefits or payment of claims.
Please complete this entire form and return to:
Blue Cross and Blue Shield of Florida, Inc.
Access Authorization Unit
Post Office Box 025314
Miami, Florida 33102-5314
