Transcription of Instructions for Completing - Blue Cross and Blue …
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Instructions for Completing - Blue Cross and Blue …
Rev 04/01/18 HCSC Privacy Office (04/23/19 BORC) Page 1 of 6 SAF-IL blue Cross and blue shield of illinois , a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,an Independent Licensee of the blue Cross and blue shield Association Instructions for Completing Standard Authorization Form to Release Protected Health Information (PHI) To Complete Form go to Page 4 Use this form to authorize blue Cross and blue shield of illinois (BCBSIL) to disclose your protected health information (PHI) to a specific person or entity. You may follow the Instructions below or call the number listed on your Member ID card if you need help Completing the form. You must complete the entire form. Please note: One authorization form can be used for multiple services or providers or you can complete the form claim byclaim, procedure by procedure, or for services provided during certain time periods.
Instructions for Completing . Standard Authorization Form . To Complete Form go to Page 4 of 5: Use this form to authorize Blue Cross Blue Shield of Illinois to ...
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