Consent for Release of Protected Health Information for Medicare Supplement Members

If you have a Blue Cross Blue Shield of Michigan Medicare Supplement plan, you must send us this completed form before we can share your protected health information, also known as PHI, with an individual or organization.

Fields with asterisks are required.

For assistance completing this form, call the number on the back of your member ID card.

First name* This field is required.

Last name* This field is required.

Date of birth* This field is required.

Phone number* This field is required. This is not a valid phone number.

Enrollee ID, found on your Blue Cross ID card* This field is required.

Street address* This field is required.

City* This field is required.

Select a state* This field is required.

ZIP code* This field is required. This is not a valid ZIP code.

You have my permission to share

Please check one

Any and all information (including personal, health, demographic, claims, billing and medical records) except Super PHI. Use the boxes listed below to include Super PHI.

Only limited information (such as for specific treatments, dates of service or billing details)

Indicate which sensitive health information you want disclosed pursuant to this authorization by checking the relevant box(es) below:

Substance abuse records (including alcoholism)

AIDS or HIV treatment records

Mental health sevices (does not include psychotherapy notes)

Family planning

Psychotherapy notes (excluded from mental health)

Person or organization you want to receive your PHI

Note: If you list a person or organization not legally required to obey privacy laws, then the information you share with them is not legally protected.

Full name of person or organization* This field is required.

What's their relationship to you?

Family member

Friend

Doctor or health care provider

Other

Cancellation of your permission to share PHI

This permission is canceled.

On this date

MM/DD/YYYY

When cancelled, or upon my death

I understand that I can cancel this permission at any time. I can cancel by submitting a written request on a standard form available online at bcbsm.com or by calling the number on the back of my member ID card. I understand that cancellation will not apply to information that has already been shared.

Authorization and signature*

I allow the use and disclosure of my protected health information as described above. This information is being released at my request. I understand that my treatment, payment, enrollment or eligibility for benefits does not depend on whether I sign this authorization. By clicking this box, I acknowledge that I am the BCBSM Member listed in the form herein. Further, I have read, understand, and agree that all the information provided in this form is true. By clicking this box, I agree that the electronic signature that appears on this form shall have the same force and effect as handwritten signatures for the purpose of validity, enforceability and admissibility. This checkbox is required.

Signature of member* This field is required.

Date* This field is required.

This field is required.

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©1996-2025 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross Blue Shield Association. We provide health insurance in Michigan. State and Federal Privacy laws prohibit unauthorized access to Member's private information. Individuals attempting unauthorized access will be prosecuted.

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Page Last Updated Fri Dec 27 13:58:31 EST 2024