A special notice to our members from Blue Cross Blue Shield of North Dakota (BCBSND):
It is our policy and our obligation under federal and state laws to protect the privacy of our member’s information. We need your understanding and cooperation to help ensure compliance with these laws. Before we can disclose information about you to someone acting on your behalf, we need to be sure that we have your permission to do so. The enclosed Authorized Representative Form allows us to use and disclose your health information with designated individuals. We also recommend written authorizations for our members who are between ages 12 and 17.
Although parents and other legal representatives generally have the authority to obtain information about their minor children, there are laws that give minors special protections regarding certain kinds of health information. In these cases, the law requires that we have the written permission of the minor child before we may disclose this information, including to their parents. Without this form, we must do a manual review of a minor’s health information to determine what information can be provided to the parents or legal guardian. Because of this manual review, there may be a delay in our response.
If you are a North Dakota resident, this authorization will remain in effect for 18 months past your Plan’s termination date. If you are a resident of another state, this authorization will terminate 12 months from the date of signature. For members under age 18, this authorization will terminate as of the member’s 18th birthday.
Please contact us at the address and/or phone number printed on the back of your ID card with any questions or changes to information on the form.