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 claim dispute, reviewing a denied procedure, or requesting a prescription cost reduction.

Once submitted, NMPSIA will review your request and follow up at 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 what your issue is. Include date of service and names of prescriptions or procedures you would like reviewed.

Please include any supporting documents

Please describe the purpose of your request (e.g., "assistance with claim," "prescription cost reduction," etc.) and specify the desired outcome.

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

5 Signatures

Personal representative: If a personal representative executes this form, that Representative warrants that he or she has authority to sign this form.

Representative name

Representative phone/email

Signature of patient (18+)

Date

Signature of policyholder

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.

Return to Homepage