This form is used
to release your protected health information as required by
federal and state privacy laws. Your authorization allows the
Health Plan (your health insurance carrier or HMO) to release
your protected health information to a person or organization
that you choose. You can revoke this authorization at any
time by submitting a request in writing to the Health Plan
(contact Member Services for further instructions). Revoking
this authorization will not affect any action taken prior to
receipt of your written request. To proceed with the
electronic release of your Sensitive Information to another
person or entity, please select continue.
To begin, complete the following
required (*) fields with your information as it matches with
Independece Blue Cross (IBX) records.
The following health plan is associated
with your IBX membership.
Complete the following fields with the
information of your new health insurance provider (the
recipient of your sensitive information).
You are sharing all of your sensitive
data by default. To restrict specific types of data from being
shared, de-select below.
Call Us: 1-800-800-800
Member Correspondence P.O.
Box 41890 Philadelphia, PA 19101 Fax | (215)