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Member's Authorization Request Form

A federal regulation called the Health Insurance Portability and Accountability Act (HIPAA) changes the way in which health care companies and medical care providers are permitted to use and disclose information about you.

BCBSNC has always been committed to protecting your health information, and now we are implementing additional policies and procedures to safeguard your information. Please read the Notice of Privacy Practices that explains in more detail our practices concerning your protected health information.

In addition, because of the new federal regulations, we want to highlight the following important changes:

• As described in the Notice of Privacy Practices, you may authorize another person to receive your protected health information.
• Effective, April 14, 2003, we will not be permitted to give your protected health information to another person unless we have legal permission. One way you can give us permission is to sign a document called an "Authorization." If you usually rely on your spouse, family member or close friend to contact us for claims or payment information, we will no longer release information to them unless we have a signed authorization from you.
• For your convenience, we have created an electronic Member's Authorization Form for this purpose. You do not have to fill out this form unless you want someone in addition to yourself to receive your protected health information. The authorization is one way to give us legal permission to do so. Parents of a minor child may continue to obtain information about the child without an authorization form.

Member's Authorization Request Form

We hope the privacy practices that we have implemented will further demonstrate our commitment to maintaining your trust and confidence in Blue Cross and Blue Shield of North Carolina. If you have any questions about the enclosed information, please call the Customer Services number on the back of your identification card.

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The drug costs displayed are estimates and may vary based on the specific quantity, strength and/or dosage of the medication, the order in which you purchase your prescriptions, and the pharmacy you use.

Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. Please contact BCBSNC for details.

Blue Cross Blue Shield of North Carolina (BCBSNC) is a Medicare Advantage organization with a Medicare contract to provide HMO and PPO plans. BCBSNC is a Medicare-approved Part D sponsor. BCBSNC does not discriminate based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability or geographic location within the service area. All BCBSNC items and services are available to all eligible beneficiaries in the service area.

Limitations, copayments, and restrictions may apply. You must be entitled to Medicare Part A and enrolled in Medicare Part B and must reside in the CMS-approved service area. You must continue to pay your Medicare Part B premium.

If you would like Medicare Advantage or Part D documents in a different language or format, or your coverage has ended and you need proof of coverage or a Certification of Health Insurance Coverage, you can call us 7 days a week, 8a.m. to 8 p.m.

®, SM Mark of the Blue Cross and Blue Shield Association. SM1 Mark of Blue Cross and Blue Shield of North Carolina.

The information on this page is current as of 10/01/2012.

Y0079_5875 CMS Approved 10012012