Authorization for Disclosure of Sensitive Health Information


Electronic Authorization for Disclosure of Health Information

This form is used to release your sensitive 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 sensitive 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.



If you are unable to fill the form online, please download the form from here.You may also submit the completed form electronically here or by mail/fax to:


Member Correspondence

P O Box 41890, Philadelphia, PA 19101-1890

Fax Number: 215-241-2042 or 1-888-457-3013 (Toll Free)

Part A. Member Information: (individual whose information will be released)

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(*) Indicates a required field.

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Part B. Health Plan: (organization that will release your information)

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(*) Indicates a required field.

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Part C. Recipient: (person that will receive your information)

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(*) Indicates a required field.

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Part D. Description of the Information to be Released:


I understand that all of my information will be used or released by my health plan on my behalf. This can include health, diagnosis (name of illness or condition), claims, doctors and other health care providers and certain financial information (such as premium billing and payment). This does not include sensitive health information (see below) unless it is approved below.



I understand that I am completing this form for the Patient Access API and that Independence Blue Cross is required to release the following data to the third-party app; (1) adjudicated claims; (2) encounter data from capitated providers; and (3) clinical data, in accordance with the CMS Interoperability Final Rule.


I also approve the release of the following types of sensitive health information (check all boxes that apply to you):

*I understand that my alcohol/substance use records are protected under Federal and State confidentiality laws and regulations and cannot be disclosed without my written consent unless otherwise provided for in the laws and regulations. I also understand that I may revoke (or cancel) this approval at any time by providing written notice to my health plan, or as described below in Part F. I understand that I cannot cancel this approval when this form has already been used to disclose information..


Part E. Purpose of this Approval



To release sensitive health information as described on this form for purposes of CMS Interoperability Final Rule.


Part F. Expiration Date of this Approval

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This authorization will remain in full force and effect until and unless: (1) the member revokes this authorization in writing to the health plan*; or (2) the member turns 18 years of age, in which case this authorization will be automatically revoked.

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*The health plan identified in Section B must be notified in writing of the member's revocation of this authorization. Such revocation shall not impact or be applicable to any data released prior to health plan's receipt and processing of the member's revocation.