Requests Authorization to Release Information Be Granted To

In accordance with the HIPAA Privacy Laws, we cannot release your health information without your written consent. If you want the information disclosed to another party, please complete, and sign this consent form.

WRITTEN AUTHORIZATION FORM

A. Member Name______ID# ______

Requests authorization to release information be granted to:

B. ______

Name Address

C. This authorization applies to: (check one)

q One service only. Date of service______Doctor/Supplier ______

q All services (all dates and all providers)

q All services from (doctor or supplier): ______

q Medicare eligibility information

q Information on other health coverage: ______

q Deductible information for (year): ______

q Copy of Explanation of Benefits for:

Date of Service Doctor / Supplier

______

D. State how long you wish this authorization to be in effect:

q One time release

q Ongoing release until otherwise revoked, or until the specified time period of this authorization exists. A revocation will not apply to information already released.

If you have any questions or need additional assistance please contact Blue Medicare Advantage Customer Service 8:00 AM - 8:00 PM 7 days a week at 1-866-508-7140 TTY users should call the Relay Service at 711. Also, if you need help understanding the information in this letter/form/document/correspondence, please contact customer service at the number above for free language translator services. You may receive a messaging service on weekends and holidays from February 15 through September 30. Please leave a message and your call will be returned the next business day.

Return this form to: Blue Medicare Advantage (HMO)

P.O. Box 8494 St. Louis, MO. 63132

Refusal to sign this authorization will have no effect on your enrollment, eligibility for benefits, or the amount Blue Medicare Advantage pays for the health services you receive.

______

Signature of Member Date

[Blue Cross and Blue Shield of Kansas City is an independent licensee of the Blue Cross and Blue Shield Association. All products are offered by Blue-Advantage Plus of Kansas City, Inc., a wholly-owned subsidiary of Blue Cross and Blue Shield of Kansas City.]

<Blue Cross and Blue Shield of Kansas City’s Blue Medicare Advantage> is an HMO with a Medicare contract. Enrollment in <Blue Medicare Advantage> depends on contract renewal.

<Document ID> [File & Use] [<accepted/approved/Deemed<date>]