## Please read these instructions carefully before completing this form.

- Complete this form if you are requesting Blue Cross and Blue Shield of Minnesota to release your information to another person or entity.
- Parents or a legal guardian may sign for a minor (under age 18) unless the minor is permitted under state law to consent to the treatment (authorized for release in this disclosure). In that case, the minor must sign.
- This form will be valid for one year from the date in which it is signed, unless an earlier expiration date or specific event is indicated below.



 

 

 

 

 ### Download a PDF version

 

[ADHI form - English](https://bluecrossmn.widen.net/content/1huigrqfub/original/authorization-for-disclosure-of-health-information.pdf)

[ADHI form - Hmong](https://bluecrossmn.widen.net/content/xcdmovewej/original/x21006cr10_1121_hmong.pdf)

[ADHI form - Spanish](https://bluecrossmn.widen.net/content/acevqbr0ee/original/adhi_form_spanish.pdf)

 

 

 

 

 

  This indicates a required field 

  I am:   The person whose information will be released. 

  The parent or legal guardian of a minor whose information will be released, except as noted above 

  The personal representative of the person whose information will be released (e.g., power of attorney, conservator, executor). 



 

  I have the appropriate documentation on file.   Yes 

  No 



 

Please contact Customer Service by calling the number on the back of your member ID card. If you don’t have a member ID card, please call **1-800-262-0823.**

 





## Section 1: The individual

The individual whose information may be disclosed



 Please enter your information exactly as it appears on your member ID Card. 

 Member first name  

 Last name  

 Member ID Number?  

 Date of Birth  

 Address 1  

 Address 2  

 City  

 State  

 ZIP/Postal Code  

 Phone  



 

## Section 2: The information to be disclosed

 Please check any or all type(s) of information that you would like us to disclose: 

  **ALL** information (including any medical records that we may have) 

  Claim Information 

  Appeal Information 

  Care/Case Management Information 

  Billing Information 

  Enrollment Information 

  Information only related to the following condition(s) 

 Disclose only information related to the following condition(s):? 

 

  Other 

 Other information you would like us to disclose:? 

 



 Please check any/all if applicable:  If this authorization is for chemical dependency program information 

  If this authorization is for psychotherapy notes. 

 

 Please provide the date range of the records to be disclosed:? (If date range is not selected, health information from any date may be disclosed) 

 From  

 To  



 

 

## Section 3: Who can receive your information?

   This information is to be disclosed to:   Individual 

  Organization (i.e. health system, business, vendor) 

  Provider (i.e. doctor, chiropractor, midwife) 



 

 List the name of the Individual, Organization or Provider  

  Check to authorize mailing of information if requested by authorized individual, organization or provider? 

 Address 1  

 Address 2  

 City  

 State  

 ZIP/Postal Code  



 

## Section 4: Authorization

I understand that I may revoke this authorization at any time by giving written notice of my revocation to Blue Cross and Blue Shield of Minnesota and Blue Plus. I understand that revocation of this authorization will not affect any action Releaser took in reliance on this authorization before it received my written notice of revocation. I also understand that without my written authorization, Releaser may not use or disclose my health information for any reason except those described in Releaser’s Notice of Privacy Policies and Practices.



**This authorization will end one year from the date this form is signed unless an earlier expiration date or specific event is indicated below:**

 

 Expiration Date?  

OR Specific Event (If applicable)?  

I understand that authorizing the disclosure of this health information is voluntary, and that I can refuse to sign this authorization.

I understand that, if the persons or organizations I authorize to receive and/or use the protected health information described above are not health plans, covered health care providers or health care clearinghouses subject to federal health information privacy laws, they may further disclose the protected health information and it may no longer be protected by federal health information privacy laws.

Releaser, its subsidiaries, affiliates, employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

 

  I understand that by typing my name in this box below constitutes a legal signature. 

 Signed: (Member)  

 Signed Date  



 Signed: (Representative)  

 Signed Date