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29306380 • 8-19
Instruction to Applicants
This form authorizes disclosure of the medical information described below of the primary applicant and (if applicable)
members of the primary applicant’s family to Blue Cross Blue Shield of North Dakota (BCBSND) for use in pre-enrollment
underwriting or risk-rating or to determine eligibility for enrollment in or benefits under a health plan.
Each individual age 12 and over, for whom the primary applicant is applying for health plan coverage, must sign this
authorization. A parent may sign this authorization on behalf of a child under age 12. If a legal representative (e.g.
Power of Attorney, Legal Guardian, etc.) signs this authorization on behalf of an individual, include a copy of the
power of attorney or other relevant document evidencing the authority to represent the individual.
By signing this form, I authorize the use and disclosure of the medical information described below for pre-enrollment
underwriting or risk-rating of health insurance coverage or to determine eligibility for enrollment or benefits under a
health plan. I understand that this authorization is a condition of enrollment in or eligibility for benefits under a health
plan for myself and (if applicable) my spouse and my dependent children. If I or (if applicable) my spouse or my
dependent children decline to sign this authorization, enrollment in a health plan may be denied.
I hereby authorize _______________________________________________________________
who has advised, treated, attended or provided care or service to me or my dependent children or is in possession
of any medical information and records (e.g., chart notes, lab/path reports, radiology reports) regarding me or my
dependent children, to furnish such medical information and records covering the last
5 years to Blue Cross Blue Shield of North Dakota (BCBSND).
I understand that this authorization applies to use and disclosure of medical information and records that may relate to
sexually transmitted disease, use of contraceptives, prenatal care, termination of pregnancy, acquired immunodeficiency
syndrome (AIDS), human immunodeficiency virus (HIV), treatment for alcohol or drug abuse, and receipt of behavioral
or mental health services.
I understand that if the recipient of this medical information is not a health care provider or health plan covered by
federal privacy regulations, this medical information may be re-disclosed and no longer protected by these federal
regulations. BCBSND is subject to federal privacy regulations and will not re-disclose this medical information except as
allowed by law.
I understand that I have the right to revoke or end this authorization at any time. I understand that in order to revoke this
authorization I must do so in writing to BCBSND. I understand that my revocation of this authorization will not aect
any action that has been taken, or any medical information that has already been used or disclosed, based upon this
authorization before BCBSND actually received my revocation.
This authorization will remain in eect for the earlier of 12 months from the date of signature or the earlier date entered
here: ______________________.
I have had full opportunity to read and consider the contents of this authorization. I understand that, by signing this
form, I am authorizing the use and/or disclosure of medical information as described in this form.
I agree that a copy of this Authorization shall be as valid as the original.
Personal Information
Name Birth Date (MM/DD/YYYY)
Maiden Name Date (MM/DD/YYYY)
Signature
(If Applicable) Legal Representative Signature Relationship
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Noridian Mutual Insurance Company
Authorization for Enrollment or Eligibility
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