Member Information

Authorized Representative

This form is used to document the designation of an Authorized Representative(s) for an individual, including a minor who has the right under applicable law to control whether a parent or guardian may have access to the minor's health information. This form authorizes the Blue Cross Blue Shield of North Dakota to use and disclose my health information with the Authorized Representative(s) designated on this form.

About your privacy

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.

Information you will need:

Member ID number

Member Information

Please complete all items of information in this section to include your member ID exactly as it appears on your card, full name, address and daytime telephone number where you can be contacted.

*Required Fields

Who Would You Like To Authorize?

Authorized use and/or Disclosure
By completing this form, you are allowing Blue Cross Blue Shield of North Dakota (BCBSND) to use and disclose your health information.

Authorized Representative
Indicate the complete name, daytime telephone number, address and relationship to you of person(s) or organization(s) authorized to receive your health information. Note: you may add more than one Authorized Representative.

By signing this form, I am allowing Blue Cross Blue Shield of North Dakota to use and disclose my health information with the Authorized Representative(s) designated on this form. I understand that if my Authorized Representative is not subject to federal or applicable state privacy laws, my health information may no longer be protected by those privacy laws and my Authorized Representative may further use and disclose my health information without my authorization.

The Authorized Representative must be someone else than self.

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What Type Of Information Would You Like Them To Access?

Instructions
You must indicate or describe the information to be disclosed. Select the option that best describes your request.

Type of Information
I allow the following information to be used or disclosed by BCBSND of my behalf.

Note: Does not include alcohol/substance abuse records protected by 42 C.F.R. Part 2, or psychotherapy notes. Requests for use and disclosure of these records should use the Authorization to Release Information Form.

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First Name : Edit
MI : Edit
Last Name : Edit
Suffix : Edit
Member ID Number : Edit
Date of Birth : Edit
Address : Edit
Address Line 2 : Edit
City : Edit
State : Edit
ZIP Code : Edit
Phone : Edit

Authorized Representatives

Information Granted : Edit

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What You Should Know About Expiration or Cancellation Of Your Authorization

This section explains when this authorization will expire.

For North Dakota residents
This authorization will remain in effect for 18 months past your plan's termination date.

For residents of all other states
This authorization will terminate 12 months from the date of signature below. If you are 18 years of age, this authorization will terminate as of your 18th birthday.

I understand that I have the right to revoke or end this authorization at any time. I understand that if I do not wish the person(s) named to remain my Authorized Representative(s), I must revoke this authorization in writing by giving written notice of my decision to the benefit plan at the address listed on the back of my ID card.

I understand that my revocation of this authorization will not affect any action that you have already taken or any information that you have already released, based upon this authorization before you receive my request to revoke it.

I also understand that my revocation may not be effective in preventing release of certain health information to a personal representative, such as a parent, guardian, or person acting in the capacity of a parent or guardian, whom applicable law allows to have access to such health information without my written permission.

Signature/authorization

I understand this authorization is voluntary. I understand my treatment, payment, enrollment 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 use and/or disclosure of protected health information, as described in this form. 

If your legal representative (power of attorney or legal guardian) signs this form on your behalf, a copy of the power attorney or relevant document evidencing the authority to represent you should be mailed to our Fargo Headquarters. Include the following:

  • Your full name
  • Reference Authorized Rep Form
  • Member full name

Blue Cross Blue Shield of North Dakota
Attn: Member Services
4510 13th Ave S
Fargo, ND 58121

By typing my name and 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.