Authorization for Release of Health Info

Authorization for Release of Health Information

Policy holder name

Patient name

Who may we respond to about this authorization?:

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

BlueCross BlueShield

Presbyterian

CVS

Davis Vision

BCBS Dental

Delta Dental

United Concordia

Name of provider:

Network selection:

In network

Out of network

Provider phone number:

Provider email:

B. Information Regarding Your Claim- 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

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

D. 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

E. 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

F. Personal representative section: 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

Signature of personal representative (if patient is under 18)

Date

Authorization for Release of Health Information

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