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Give Permission to Access Health Information

Authorization to Release Information (ADHI) (Medical Coverage)

This form is used to request and authorize Blue Cross Blue Shield of North Dakota to use and disclose my health information with another person or entity.

Information you will need:
Member ID number

Member Information

This form should be filled out by the member that is authorizing Blue Cross Blue Shield of North Dakota (BCBSND) to use and disclose their health information to another person or entity.

*Required Fields

Who Would You Like To Authorize?

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.

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What Type Of Information Would You Like Them To Access?

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

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Member First Name : Edit
MI : Edit
Member Last Name : Edit
Suffix : Edit
Member ID : Edit
Date of Birth : Edit
Phone : Edit
Address : Edit
Apt. or Suite Number : Edit
City : Edit
State : Edit
ZIP Code : Edit

Authorized Representatives

Information Granted : Edit

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Expiration and Revocation

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.

I may revoke this authorization at any time by giving written notice of revocation to BCBSND Member Services at the address listed on the back of my member ID card. I understand that my revocation of this authorization will not affect any action that you have taken, or any information that you have released, based upon this authorization before you actually receive my request to revoke it.

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

By checking this box, I understand that I am creating an electronic signature that carries the same legal obligations as a written signature and am agreeing to all terms and conditions.

If I do not check this box my request will not be processed.