Get Authorized Delegate Form - Blue Cross And Blue Shield Of Louisiana

Filling out the Authorized Delegate Form from Blue Cross And Blue Shield Of Louisiana is essential for providing permission to share your protected health information with designated individuals or organizations. This guide will walk you through each section of the form, ensuring that you complete it accurately and efficiently.

Follow the steps to fill out the Authorized Delegate Form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with Section A, which states the purpose of the form. This section affirms that the form is submitted at your request for BCBSLA to share your health information.
3. Proceed to Section B, where you will give BCBSLA permission to disclose any personal information protected by law. Be aware that this may include detailed medical information, but certain types require additional authorization.
4. Complete Section C by providing your member information. Include your name, address, city, state, zip code, and member ID number or Social Security number as required.
5. In Section D, list the person(s) or organization(s) who will receive your protected information. Ensure to provide their name, address, city, state, zip code, date of birth or tax ID, and driver's license number.
6. Move to Section E for important information, noting that not completing the form does not affect your services from BCBSLA, but sharing your information will be restricted.
7. In Section F, you must sign the form, confirming that you understand it and agree to share your information. Include the date of signing.
8. If applicable, fill out Section G if a legal representative is signing on your behalf. Include their name and relationship to you. Remember to attach any necessary legal documentation.
9. After completing the form, save your changes. You may download, print, or share the form as needed before submission.

Complete your Authorized Delegate Form online today for seamless management of your health information.