Get A46163_6-13 Bsc Authorization Form - Blue Shield

Filling out the A46163_6-13 BSC Authorization Form is an essential step in allowing Blue Shield to manage and share your health information as authorized by you. This guide provides clear instructions to help you complete this form efficiently and accurately.

Follow the steps to fill out the A46163_6-13 BSC Authorization Form online:

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Fill in the section identifying the person whose information is to be disclosed, referred to as the 'Member.' Include their name, address, subscriber ID number, and date of birth.
3. Provide the details of the person or organization authorized to receive the Member’s information, known as the 'Recipient.' Enter the Recipient’s name, address, and their relationship to the Member.
4. Indicate what information may be disclosed to the Recipient by checking the appropriate box. You can choose either to authorize any information that Blue Shield maintains or specify particular types of information.
5. If applicable, specify whether the Recipient is authorized to receive Sensitive Information by selecting 'Yes' or 'No.' If 'Yes,' choose either the psychotherapy notes or additional sensitive information types to authorize.
6. State the purpose of the requested use or disclosure of information by selecting the corresponding checkbox or providing a specification.
7. Provide an expiration date for the authorization, which typically lasts for one year unless specified otherwise.
8. Sign and date the authorization, confirming that you understand and agree to its terms.
9. If a representative or guardian is signing on behalf of the Member, include their name, relationship to the Member, and any required documentation demonstrating their authority.
10. Finally, keep a copy of the completed Authorization for your records and return the signed form to Blue Shield of California Customer Service.

Complete your A46163_6-13 BSC Authorization Form online today for efficient management of your health information.