Get Standard Authorization Form

Completing the Standard Authorization Form online allows you to authorize the release of your protected health information in a secure and efficient manner. This guide provides you with the necessary steps to accurately fill out the form, ensuring your information is correctly disclosed.

Follow the steps to fill out the Standard Authorization Form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. In Section I, provide your personal information, including your name, date of birth, group number, identification/subscriber number, address, social security number, and contact details.
3. In Section II, state the authorization for Blue Cross and Blue Shield of Texas to disclose your protected health information. List the persons or organizations authorized to receive this information along with their relationship to you and the purpose for the disclosure.
4. Move to Section III to provide a specific description of the information to be used or disclosed. Complete Parts A and B, indicating whether you authorize the release of sensitive health information under state law and select the categories of protected health information you wish to disclose.
5. In Section IV, indicate the expiration date of the authorization by choosing from the available options or inserting a specific date or event. Understand your right to revoke this authorization at any time.
6. In Section V, sign and date the form. Ensure that the signature is provided by the individual, parent of a minor child, or their personal representative.
7. If applicable, complete the section for personal representatives by providing their name, address, and relationship to the individual. Remember to attach any necessary legal documents if you are signing on behalf of someone else.
8. Before submitting the form, keep a copy for your records. You can do so by making a photocopy or using a duplicate authorization form.
9. Finally, mail your completed and signed authorization to the designated address for Blue Cross and Blue Shield of Texas as provided in the form.

Complete your documents online today for a smooth and secure process.