By signing this form, I am allowing Blue Cross Blue Shield of North Dakota to use and disclose my health information as requested in the Grant Access section of this form with the following individual(s) and organization(s) listed below.

I understand that if the individual(s) and/or organization(s) is not subject to federal or applicable state privacy laws, my health information may no longer be protected by those privacy laws, and the individual(s) and/or organization(s) may further use and disclose my health information without my authorization. I acknowledge that my authorization is voluntary.

I allow the following information to be used or disclosed by BCBSND on my behalf.

This authorization will be valid for this one-time release of information unless otherwise specified below. Any date specified cannot exceed 12 months from the date of the covered member's submission of the form.

Signature/authorization

I understand that this authorization is voluntary. I understand my treatment, payment, and enrollment in a health plan or eligibility for benefits is not conditioned on receiving this authorization.

I have had full opportunity to read and consider the contents of this authorization. I understand that, by signing this form, I am confirming my authorization for the use of and/or disclosure of my protected health information, as described in this form.

Signed by