Member Authorization Request Form BlueCross NC
This form allows Blue Cross Blue Shield of North Carolina members to authorize the disclosure of their Protected Health Information (PHI). It outlines the required information needed for the authorization. The form must be completed for authorized individuals to access certain health information.
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How do I fill this out?
To fill out this form, begin by entering the member's personal information. Next, specify the individual or entity authorized to receive the Protected Health Information. Finally, indicate the purpose of the disclosure and provide a signature for the authorization.
How to fill out the Member Authorization Request Form BlueCross NC?
1
Enter the member's name and date of birth.
2
Fill in the Blue Cross NC ID number.
3
Designate the person or entity to receive the PHI.
4
State the purpose of the disclosure.
5
Sign and date the form.
Who needs the Member Authorization Request Form BlueCross NC?
1
Parents who want to manage their adult children's health information.
2
Guardians of dependents aged 14-18 requiring health consultations.
3
Members needing to share PHI with a healthcare provider.
4
Individuals assisting members with health plan coordination.
5
Patients seeking mental health support that requires shared information.
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What are the instructions for submitting this form?
To submit the Member Authorization Request Form, you can send it via mail to Blue Cross and Blue Shield of North Carolina at PO Box 2291, Durham, NC 27702. Alternatively, you may consider faxing it to the number provided on the form or utilizing any online submission options stated. Ensure that you retain a copy of the completed form for your records and consult customer service if you have questions about the submission process.
What are the important dates for this form in 2024 and 2025?
Important dates for the Member Authorization Request Form include the current processing deadlines for any PHI disclosures. It is advised to submit this form promptly, especially before the expiration of health-related coverage policies.
What is the purpose of this form?
The primary purpose of the Member Authorization Request Form is to allow Blue Cross NC members to legally authorize the disclosure of their Protected Health Information (PHI). This form helps facilitate communication between members and their designated representatives or healthcare providers. By completing this authorization, members ensure that essential health information can be shared with the people who need it for care and management.
Tell me about this form and its components and fields line-by-line.
- 1. Member's Name: The full name of the Blue Cross NC member.
- 2. Date of Birth: The birth date of the member.
- 3. Blue Cross NC ID Number: The member's unique identification number assigned by Blue Cross.
- 4. Authorized Person/Entity: The person or entity designated to receive the PHI.
- 5. Purpose of Disclosure: The reason for authorizing the disclosure of information.
What happens if I fail to submit this form?
Failure to submit this form may result in delayed access to important health information for authorized individuals. This can hinder effective care coordination and management that requires sharing of Protected Health Information.
- Delayed Information Access: Authorized individuals may not receive critical health details timely.
- Inability to Coordinate Care: Healthcare providers may lack necessary data for managing treatment.
- Legal Compliance Issues: Without authorization, disclosing PHI may violate privacy regulations.
How do I know when to use this form?
- 1. For Family Members: To allow family members to assist in managing health information.
- 2. For Healthcare Providers: When you need to share PHI with a healthcare provider.
- 3. For Legal Representatives: To enable legal representatives to handle health-related matters for the member.
Frequently Asked Question
How do I authorize someone to access my PHI?
Complete the Member Authorization Request Form with the designated individual's information.
Can I revoke my authorization after submitting?
Yes, you can revoke your authorization by providing written notice to Blue Cross NC.
What is PHI?
Protected Health Information refers to any personal health data that relates to an individual's medical history.
Do I need to fill out this form for anyone?
No, filling out this form is voluntary and not required for coverage.
Where do I submit the completed form?
Send the completed form to the address indicated on the form or through the specified channels.
What information do I need to provide?
You'll need to provide member details, the designated individual's information, and your signature.
Is there a fee to submit this form?
No, there is no fee associated with submitting the Member Authorization Request Form.
What if I have questions about filling out the form?
You can contact Blue Cross NC customer service for assistance with the form.
Can I share my PHI with multiple people?
Yes, but you must fill out separate forms for each individual.
How long does the authorization last?
The authorization lasts until the policy expires or until a specified date if indicated.
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