Authorization for Release of Health Information

Use this form to authorize NMPSIA to access and share your health information with your insurance carrier on your behalf. This is typically needed when you need help resolving a medical/prescription, dental, or vision claim dispute or reviewing a denied procedure.

Once submitted, NMPSIA will review your request and follow up via the contact information you provide. A PDF copy of your completed form will be downloaded to your device for your records.

1 Personal Information

Policy holder name

Patient name

How should we contact you about this authorization?

Email address

Phone number

2 Insurance & Provider Details

Specific organization(s) authorized to provide the information (please select all that apply): *

BlueCross BlueShield

Presbyterian

CVS

Davis Vision

BlueCare Dental

Delta Dental

United Concordia

Name of provider:

Network selection:

In network

Out of network

Provider phone number:

Provider email:

3 Claim Details

Please provide detailed information of your matter. Include date of service and names of medication or procedures you would like reviewed and specify the desired outcome.

Please attach any supporting documents, such as Explanation of Benefits (EOB), Bills, provider letters, denial notices, letter of medical necessity or prescription information to assist with the review.

4 Terms & Conditions

Right to revoke. I understand that I have the right to revoke this authorization at any time by notifying NMPSIA in writing at 410 Old Taos Highway, Santa Fe, NM 87501. I understand that the revocation is only effective after it is received and logged by NMPSIA. I understand that any use or disclosure made prior to the revocation under this authorization will not be affected by a revocation.

I agree to the above statement *

Disclosure. I understand that after this information is disclosed, federal law might not protect it and the recipient might redisclose it. I understand that I am entitled to receive a copy of this authorization. I understand that this authorization will expire when my inquiry or appeal has been acted upon by NMPSIA.

I agree to the above statement *

Personal representative. I authorize NMPSIA to communicate with the individual listed here as my personal representative regarding my request and to disclose only the minimum necessary information needed to assist with this matter. This authorization applies only to this request and may be revoked at any time in writing. Revocation will not apply to actions already taken.

I agree to the above statement

5 Signature

I acknowledge and agree that by typing my name and today's date in the designated boxes in this form and clicking "Review and Submit" I am electronically signing this release, which will have the same legal effect as the execution of this document by a written signature and shall be valid evidence of my intent and agreement to be bound by its terms. I understand that by choosing to electronically sign this release form, this release will be securely stored. I also understand that if I do not electronically sign this release form, it will not be submitted successfully.

Signature of Patient or Legal Guardian (if patient is under the age of 18)

Date

Review your submission

Please confirm the information below is correct.

By signing electronically, I (Patient, Policy Holder and/or Personal Representative) confirm that I am the individual identified in this document and that I have read, understood, and agree to the terms and conditions outlined herein. My electronic signature is equivalent to my handwritten signature and is intended to have the same legal effect as a physical signature. I understand that I am providing consent to use my electronic signature in connection with this document and that I have the right to withdraw my consent at any time.

If I am signing on behalf of another person/entity represented in this form, I certify that I am legally authorized to do so.

Your form has been submitted successfully!

A PDF copy of your authorization form has been downloaded to your device. If the download did not start automatically, please check your browser's download settings.

NMPSIA will review your submission and respond to the contact email provided on your form.

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