Fillable Request for Release of Members Protected Health Information (Blue Cross Blue Shield of Michigan)

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Request for Release of Members Protected Health Information (Blue Cross Blue Shield of Michigan)

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The Request for Release of Members Protected Health Information (Blue Cross Blue Shield of Michigan) form is 2 pages long and contains:

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  • 12 check-boxes
  • 12 other fields

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Request for Release of Member’s
Protected Health Information
Use this form if you are a Blue Cross* member’s personal
representative and you need access to the member’s protected
health information (also known as PHI).
A
Representative who is requesting information
Please print your name below and check the box that describes your relationship to the member.
Your full name ______________________________________________________________________________
Relationship to member (check one)
Legal guardian: Attach guardianship documentation, which must have a court’s stamp and signature.
Power of attorney: Attach power of attorney (must include authorization of the release of
healthcare information).
Executor: Attach letter of appointment of executorship, which must have a court’s stamp
and signature.
Patient Advocate: Attach Designation of Patient Advocate form, signed by member.
Other: Please explain your relationship to the member and attach any supporting documentation.
B
Member whose information will be shared
This form can only be used for one member. Please submit a separate form for each member.
Name __________________________________________________ Date of birth _______________________
Enrollee ID (number on ID card beginning with 1 to 3 letters) ______________________________________
Address _____________________________________________ Daytime phone _______________________
City _________________________________________________ State ___________ ZIP _________________
C
Protected health information to be shared (check one)
Any and all information (including personal, health, demographic, claims, billing and
medical records)
Only limited information (such as for specic treatments, dates of service or billing details)
(please describe)____________________________________________________________________________
Please check below if you would also like to include any of the following
highly protected information (known as Super PHI):
Substance abuse records (including alcoholism)
AIDS or HIV treatment records
Mental health services (does not include psychotherapy notes)
Form continues on page 2.
* “Blue Cross,” “we” or “us” refers to Blue Cross Blue Shield of Michigan, Blue Care Network, Blue Care
Network Service Company, Blue Care of Michigan, Inc. or Blue Cross Complete of Michigan.
WF 16097 SEP 16
Page 1 of 3
SIGN HERE
ATTACH
Request for Release of Member’s Protected Health Information, continued
D
Expiration and cancellation
This permission will expire (check one box only):
On this date (month, day and year, MM/DD/YYYY) ____________________________________________
When canceled, or upon my death
I understand that I can cancel this authorization at any time by submitting a written request on a
standard form, available online at bcbsm.com or by calling the number on the back of the member’s
ID card. I understand that cancellation will not apply to information that has been released by
this authorization.
E
Authorization and signature
I allow the use and disclosure of protected health information as described above. This information is
being released at my request. I understand that treatment, payment, enrollment or eligibility for benets
does not depend on whether I sign this authorization. Note: If information is shared with a person or
organization that is not legally required to obey privacy laws, the information may be shared with
others and no longer protected.
Signature of personal representative
_____________________________________________________ Date ____________________
You must attach proof of your relationship to the member (See section A of this form
for examples of acceptable documentation).
IMPORTANT: Please read the form over carefully and be sure you have included all necessary
information and documentation. We cannot take additional information by phone, fax or email. If
information is missing we will have to contact you and request a new form.
Mail completed consent form and documentation to:
Blue Cross Blue Shield of Michigan
Mail Code X425
600 East Lafayette Blvd., Detroit, MI 48226
or fax to: 1-866-894-3101.
For additional assistance completing this form, call the number listed on the back of the member’s ID card.
Medicare Plus Blue, BCN Advantage and Prescription Blue are PPO, HMO, HMO-POS and PDP plans
with Medicare contracts. Enrollment in Medicare Plus Blue, BCN Advantage and Prescription Blue
depends on contract renewal.
WF 16097 SEP 16
Page 2 of 3
Y0074_F_PHIAuthFormRep FVNR 0615
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.
إاذﻛ ﺖﻨأ ﺖﻧ وأﺷ ﺺﺨﺧآﺮﺴﺗﺎﻋﺪهﺤﺑﺟﺎﺔﻟﺴﻤﺎﻋﺪة ،ﻠﻓﺪﯾﻚاﻟﺤ ﻖ ﻲﻓاﻟﺼﺤﻮ لﻠﻋ ﻰ
اﻟﺴﻤﺎﻋﺪ ةﻟاوﻤﻠﻌﻮﻣﺎتاﻀﻟﺮوﯾرﺔﺑﻠﺘﻐ ﻚود نﯾأﺔﺗﻠﻜﺔﻔ. ﻠﻟﺘﺤ ثﺪﻟإ ﻰﺘﻣﺮﺟﻢاﺼﺗﻞﺑﺮﻗ ﻢ
ﺧﺪﻣﺔاﻤﻌﻟﻼءاﻟﻤﺟﻮ دﻮﻋ ﻰﻠﮭظﺮﺑﻄﺎﻗﺘﻚ ، وأﺑﺮﻗ ﻢ877-469-2583 TTY:711 ،ذإ ا
ﻟ ﻦﻜﺗ ﻢﺸﻣﺘﺮﻛ ﺎﺑﻟﺎﻔﻌﻞ.
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

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،
،





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
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،
.
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877-469- :711

.
2583 TTY
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；如果您還不是會員，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.
Nếu quý vị, hay người mà quý vị đang giúp đỡ, cần trợ giúp, quý vị
sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của
mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi số
Dịch vụ Khách hàng ở mặt sau thẻ của quý vị, hoặc 877-469-2583,
TTY: 711 nếu quý vị chưa phải là một 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 정보를 귀하의 언어로 비용 부담 없이 얻을 수
있는 권리가 있습니다 . 통역사와 대화하려면 귀하의 카드
뒷면에 있는 고객 서비스 번호로 전화하거나 , 이미 회원이
아닌 경우 877-469-2583, TTY: 711 로 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.
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Request for Release of Members Protected Health Information (Blue Cross Blue Shield of Michigan)

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Completed 10 February 2021

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