Authorization for Disclosure of Health Information

This form is used to authorize Blue Cross to release your protected health information (PHI) to another person or entity.

Please read these instructions carefully before completing this form.

  • Complete this form if you are requesting Blue Cross and Blue Shield of Minnesota to release your information to another person or entity.
  • Parents or a legal guardian may sign for a minor (under age 18) unless the minor is permitted under state law to consent to the treatment (authorized for release in this disclosure). In that case, the minor must sign.
  • This form will be valid for one year from the date in which it is signed, unless an earlier expiration date or specific event is indicated below.
This indicates a required field
I am:
I have the appropriate documentation on file.

Please contact Customer Service by calling the number on the back of your member ID card. If you don’t have a member ID card, please call 1-800-262-0823.

Section 1: The individual

The individual whose information may be disclosed
Please enter your information exactly as it appears on your member ID Card.

Section 2: The information to be disclosed

Please check any or all type(s) of information that you would like us to disclose:
(If date range is not selected, health information from any date may be disclosed)

Section 3: Who can receive your information?

This information is to be disclosed to:

Section 4: Authorization

I understand that I may revoke this authorization at any time by giving written notice of my revocation to Blue Cross and Blue Shield of Minnesota and Blue Plus. I understand that revocation of this authorization will not affect any action Releaser took in reliance on this authorization before it received my written notice of revocation. I also understand that without my written authorization, Releaser may not use or disclose my health information for any reason except those described in Releaser’s Notice of Privacy Policies and Practices.
This authorization will end one year from the date this form is signed unless an earlier expiration date or specific event is indicated below:

I understand that authorizing the disclosure of this health information is voluntary, and that I can refuse to sign this authorization.

I understand that, if the persons or organizations I authorize to receive and/or use the protected health information described above are not health plans, covered health care providers or health care clearinghouses subject to federal health information privacy laws, they may further disclose the protected health information and it may no longer be protected by federal health information privacy laws.

Releaser, its subsidiaries, affiliates, employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.